Simultaneous correction of duodenal atresia due to annular pancreas and malrotation by laparoscopy

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

INTRODUCTION

Laparoscopic 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.

METHODS

We 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.

RESULTS

There 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.

CONCLUSIONS

Our 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.

Successful Pregnancy Outcome after Amnioreduction Treated Acute Polyhydramnios Caused by Duodenal Atresia

The aim of our manuscript is to report of a successful perinatal outcome after treatment of acute polyhydramnios caused by duodenal atresia. A 34-year-old G3P1 was referred due to polyhydramnios in the 30th week of pregnancy. Ultrasound revealed polyhydramnios, amniotic fluid index (AFI) 28, and a double bubble sign that indicated duodenal atresia and dilatated oesophagus. In the 32nd week of gestation, the volume of amniotic fluid increases, AFI 35, along with symptoms of dyspnea and abdominal pain. Due to the clinical picture and the early gestational age, it was decided to perform an amnioreduction. In the 36th week of gestation cesarean section was performed. The baby was taken for exploratory laparotomy and found to have a simultaneous complete duodenal atresia and annular pancreas with associated dilated the first portion of the duodenum and the stomach. A side-to-side duodenoduodenostomy via single-layer hand-sewn anastomosis was performed over a transanastamotic feeding tube (TAFT). The postoperative course was uneventful. Amnioreduction is useful and safe in the treatment of acute polyhydramnios caused by duodenal atresia and thus has a significant role in prolonging gestation until fetal maturity.

Laparoscopic side-to-side duodenoduodenostomy versus diamond-shaped anastomosis for annular pancreas in the neonate

BACKGROUND

The aim of this report is to present our experience of the last 5 years with repairs of congenital annular pancreas in neonates to determine the efficacy and outcomes of laparoscopic side-to-side duodenoduodenostomy compared to laparoscopic diamond-shaped anastomosis.

METHODS

A total of 35 patients with congenital annular pancreas in neonates were operated by laparoscopic procedure at our hospital during January 2015 and September 2020. Twenty patients underwent laparoscopic side-to-side duodenoduodenostomy (group A), and 15 patients of the control group underwent laparoscopic diamond-shaped anastomosis (group B). The clinical data between the two groups were compared.

RESULTS

The operative time is 77.5 ± 18.7 min in group A (range 50 ~ 125 min), and 92.5 ± 20.2 min in group B (range 75-155 min) (P = 0.029). Feedings started on postoperative day 4.5 ± 0.9 (range 3-6 days) in group A, whereas 6.5 ± 0.8 (range 4-7 days) in group B (P = 0.013). The cases in group A were discharged uneventfully in a mean of 9.2 ± 2.3 (range 7-15 days) postoperative day, and 11.4 ± 3.7 days (range 8-20 days) in group B (P = 0.041). The cases of group A have been followed up for 33.1 ± 15.4 months (range 3-60 months), group B had been followed up for 32.0 ± 14.0 months (range 6-55 months) (P > 0.05), and all the cases were doing well at the last follow-up examination.

CONCLUSION

Laparoscopic side-to-side duodenoduodenostomy is beneficial to the recovery of intestinal function postoperatively in the neonate with annular pancreas.

Laparoscopic Ladd Procedure for Malrotation in Newborns and Infants

BACKGROUND

Laparoscopic approach for malrotation has become more popular for neonates and in cases with volvulus, but its safety and efficacy remains controversial. This study reviewed laparoscopy outcomes in neonate/infant malrotation.

METHODS

Medline/PubMed and Lilacs databases were reviewed. Data from studies published in English/Spanish between 1995 and 2019 were collected. Results are presented as percentages and means/medians; logistic regression was used to study possible associations.

RESULTS

Nineteen papers offered 99 neonates/infants with median age and weight of 10.5 days and 3.5 kg, respectively. Ladd's procedure was performed in 95 (96%) patients and bands' division in 4 (4%); appendectomy was not included in 16 (16.2%) patients, and cecopexy was not performed in all cases. Volvulus was reported in 39 (39.4%) patients. There were 11 conversions (11.1%) and 10 recurrences of symptoms (10.1%) that required reintervention. An association was found between volvulus and recurrence (P = .05) and the need for conversion (P < .01). There were 10 (10.1%) minor complications and no mortality. The median follow-up was 10 months.

DISCUSSION

Laparoscopic approach to malrotation is feasible and safe in hemodynamically stable neonates/infants without intestinal necrosis and is associated with 11% conversion rate and 10% reinterventions. The presence of volvulus is associated with recurrence and conversion. Laparoscopic Ladd's procedure with appendectomy and without cecopexy is the commonly practiced approach that is associated with minor complications.

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

PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Is laparoscopic surgery better than open surgery for the repair of congenital duodenal obstruction? A review of the current evidences

BACKGROUND/PURPOSE

Whether laparoscopic surgery is superior to open surgery in the repair of congenital duodenal obstruction remains controversial. The objective of this study is to systematically review the literatures, which compare the outcomes of these two operative approaches.

METHODS

A systematic review of the studies comparing these two surgical approaches since 2000 was carried out.

RESULTS

Four retrospective cohort studies comprising 180 patients were eligible for analysis. Duodenal atresia was the most common diagnosis (62.3%). Overall, there were no statistically significant differences in terms of operative duration (SMD: 0.75, 95% CI: 0.46-1.04), ventilator dependence (SMD: 0.04, 95% CI: -0.22 to 0.29), time to initial enteral feeding (SMD: 0.12, 95% CI: -0.14 to 0.38), time to full enteral feeding (SMD: 0.18, 95% CI: -0.15 to 0.50) and hospital stay (SMD: -0.03, 95% CI: -0.29 to 0.22). The overall incidences of anastomotic complications in laparoscopic vs open groups were 4.4% vs 1.8%. Two cases of missed distal pathology were reported in the laparoscopic group.

CONCLUSIONS

Laparoscopic surgery is feasible in the repair of CDO. Study with larger sample size is needed for further analysis to examine whether open or laparoscopic approach is superior. Meanwhile, it is still safe to practice laparoscopic repair of CDO in skilled surgeons, with attention to the possibility of distal pathology.

Persistent Nonbilious Vomiting in a Child: Possible Duodenal Webbing

An association between malrotation and congenital duodenal webbing is rare. We present our experience with four patients at two centers, and a review of published reports. There are currently 94 reported cases of duodenal pathology associated with malrotation. However, only 15 of the 94 cases (15.9%) include patients with malrotation and a duodenal web. We suggest that nonbilious vomiting in a child must prompt the surgeon to consider duodenal pathology even in the presence of malrotation.

Minimal invasive surgery in the newborn: current status and evidence

The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.

Minimally invasive surgery in the neonate

The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.

Prenatal diagnosis of annular pancreas: reliability of the double bubble sign with periduodenal hyperechogenic band

OBJECTIVE

To evaluate the power of prenatal 2-D ultrasound examination in the 2nd trimester as a method of choice for accurate diagnosis of annular pancreas.

METHODS

Co-incidence of the double bubble sign (often accompanying gastroduodenal dilatation) together with a hyperechogenic band around the duodenum (corresponding with the tissue of annular pancreas) was used as a diagnostic criterion. Findings from postnatal surgery served for verification.

RESULTS

From 7,897 screened pregnancies, annular pancreas was proven in the cases where both signs were present, but never without the hyperechogenic band (N(1) = 3, N(2) = 3, p < or = 0.05). Sensitivity and specificity were 100%.

CONCLUSIONS

More multicentric studies are required to test this approach. The following diagnostic strategy is reasonable at the present time: when the double bubble sign is discovered, always suspect annular pancreas and look for the second sign: hyperechogenic bands around the duodenum. Also look for known associated anomalies, and vice versa, if any of associated anomalies are noted, also search specifically for the signs of annular pancreas.

Laparoscopic duodenoduodenostomy in a newborn with situs inversus totalis

Situs viscerum inversus is a rare embryologic anomaly with a mirror-image transposition of the normal anatomy of organs. The coexistence with the duodenal atresia is extremely rare. This report describes a newborn with duodenal atresia and situs inversus totalis who was managed laparoscopically. According to our knowledge, this is the first report of this type of associated anomaly to be successfully managed by the laparoscopic approach.

Exocrine drainage into the duodenum: a novel technique for pancreas transplantation

Simultaneous pancreas-kidney transplantation is the treatment of choice for patients suffering from type 1 diabetes mellitus and end-stage renal failure secondary to diabetic nephropathy. Until 1995, about 90% of pancreas transplantations were performed with exocrine drainage into the bladder. Since then the proportion of pancreas transplants with enteric drainage increased steadily because of frequency of complications and long-term disadvantages of bladder drainage. However, the use of enteric drainage removes the opportunity to monitor pancreatic allograft function either by measuring urinary amylase or by carrying out biopsy via cystoscopy. We report a new technique of exocrine pancreatic drainage into the recipient duodenum. This modification places the pancreas graft including the duodenal anastomosis in a retroperitoneal location and, importantly, allows easy graft monitoring via gastroscopy.

Laparoscopic repair of neonatal gastric perforation

BACKGROUND

Gastric perforation is a rare, life-threatening condition in neonates. To avoid deterioration, prompt surgical treatment is mandatory.

PATIENTS

We report on 2 neonates (1 and 8 days old) with feeding tube associated gastric perforation managed laparoscopically by single layer suture repair. Both children suffered from severe peritonitis. Operative time was 60 minutes in both cases. Oral feeding was started on postoperative day 3 and 7, respectively. No complications regarding the gastric perforation were encountered on follow-up (11 and 8 months, respectively) in both cases.

CONCLUSIONS

We recommend laparoscopic suture repair as a safe and feasible method for surgical treatment of gastric perforation in neonates. These appear to be the first reported cases using this procedure for treatment of neonatal gastric perforation.

Annular Pancreas in the Adult: Management with Laparoscopic Gastrojejunostomy

Annular pancreas is an uncommon congenital anomaly associated with duodenal atresia in neonates. Rarely, the condition may manifest later in life. These symptoms include abdominal pain, nausea, and vomiting and usually arise due to obstruction to gastric emptying. Abdominal CT scan with high resolution and angiography protocol and magnetic resonance imaging are useful in confirming the presence of annular pancreas. Operative management involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates with annular pancreas. In adults, the duodenum is less mobile, and duodenojejunostomy or gastrojejunostomy are recommended. We report two cases of annular pancreas in adults treated with laparoscopic gastrojejunostomy.

Minimally invasive surgery in the neonate: review of current evidence

Minimally invasive surgery has been one of the most important surgical advances in the last 15 years. The development of smaller instruments has allowed pediatric surgeons to apply this rapidly evolving technology to neonates. Congenital neonatal deformities including tracheoesophageal fistula, patent ductus arteriosus, duodenal atresia and anorectal malformations are now being managed with minimally invasive surgery. This article summarizes the status of these techniques in neonates.