Abstract
Abstract
Introduction:
Laparoscopic duodenoduodenostomy can be performed to repair congenital duodenal obstructions from atresia or duodenal web. There are only a few published case series in the literature. We are reporting on a single surgeon's experience with the operation and discuss the technical aspects of the operation.
Material and Methods:
A retrospective chart review was performed using the electronic medical record identifying all patients who underwent laparoscopic duodenoduodenostomy or duodenojejunostomy at two institutions by a singular surgeon.
Results:
Fifteen patients were identified as having undergone laparoscopic duodenoduodenostomy from 2010 until 2017. The weight at the time of the operation ranged from 1.5 to 8.7 kg (median 2.5 kg). The age ranged from 0 days to 15 months (median 3 days). Operative time (including other procedures) ranged from 2 hours 10 minutes to 3 hours 45 minutes with a median of 2 hours 55 minutes. One case was converted to open due to poor visualization. One patient developed a stricture that required open anastomotic revision 4 weeks after the initial surgery. In 1 patient, an enterotomy in the first portion of the duodenum was created from a retraction stitch—this was immediately recognized and repaired by primary laparoscopic closure. One patient had a small anastomotic leak that was treated with antibiotics. There were no mortalities and no intraoperative blood loss requiring transfusion.
Conclusion:
Laparoscopic duodenoduodenostomy is an operation that can be performed with excellent outcomes following simple steps that are easily taught in a teaching setting.
Introduction
Congenital duodenal obstruction includes duodenal atresia, duodenal stenosis, duodenal web, and annular pancreas, with the most common obstruction being duodenal atresia. Duodenal atresia affects ∼1 in 6,000 neonates, and presents as proximal intestinal obstruction at birth. The traditional method of repair has been open duodenoduodenostomy 1 through a transverse right upper quadrant laparotomy incision. With improvements in laparoscopic instruments and experience, laparoscopic duodenoduodenostomy can now be performed to repair congenital duodenal obstruction from atresia or duodenal web. The first reported laparoscopic repair was performed in 2001. 2 There are only a few published retrospective case series in the literature comparing open with laparoscopic repair of congenital duodenal obstruction.1–3
The purpose of this study was to report outcomes in patients who underwent laparoscopic repair of congenital duodenal obstruction by a single surgeon and also examine the technical aspects of the surgery.
Materials and Methods
Study design
A retrospective review was performed between 2010 and 2017 of all patients who had undergone a laparoscopic duodenoduodenostomy by a single surgeon at two institutions within the same city. The majority of surgeries were performed at a tertiary care center that serves as a training institution for residents and fellows. The study was approved by the Colorado Institutional Review Board.
Participants
The main eligibility criterion was having undergone laparoscopic duodenoduodenostomy for duodenal obstruction by a single surgeon. The surgeon's case log was reviewed to obtain eligible patients that resulted in 15 patients being included for review.
Surgical procedure
The operation was performed creating a “diamond” shaped duodenoduodenostomy between the first portion of the duodenum and the third portion. In the case of rotational anomaly, the distal duodenum or proximal jejunum was used. The anastomosis was created using 5–0 or 4–0 Vicryl suture on a Tetrology of Fallot or Renal Bypass needle. The posterior wall of the anastomosis was created using a running stitch. The anterior wall was closed with interrupted suture. Most operations were completed with a single 5 mm umbilical port for the camera, in addition to two “stab” incisions used as working ports. All knots were tied intracorporeally. As needed, a retracting stitch was placed into the first portion of the duodenum to facilitate exposure. Only 1 patient underwent placement of a transanastomotic feeding tube.
Data review
The electronic medical records of selected patients were reviewed for gender, age at time of surgery, weight at time of surgery, gestational age at birth, diagnosis of trisomy 21, presence of a rotational anomaly, type of duodenal obstruction, sutures used, additional surgeries during same anesthetic, presence of a trainee during surgery, operative time, conversion to open surgery, postoperative complications, mortality, and requirement for blood transfusion postoperatively.
Statistics
Descriptive analysis was performed using Microsoft Excel. Median with interquartile range was used for continuous variables, and proportions were used for categorical variables.
Results
Participant characteristics
There was an equal distribution of males and females (46.7%). The median weight at the time of surgery was 2.4 (2.0–3.1) kg, and the median age at surgery was 3 (2.0–7.5) days. In terms of other anomalies, 5 of 15 (33.3%) had trisomy 21, 3 of 15 (20.0%) had a malrotation, and 4 of 15 (26.7%) had nonrotation. The majority (11 of 15, 73.3%) of duodenal obstruction was due to duodenal atresia with only 4 of 15 (26.7%) presenting with duodenal web and none with annular pancreas (Table 1).
Patient Characteristics
Median (range).
Surgical parameters
All procedures were performed by the same surgeon or under his direct supervision. In all cases, a pediatric surgery fellow or surgery resident participated and performed a part of the procedure.
The majority of cases, 9 of 15 (60%), included additional surgeries, and the median operating time was 175 (157.5–193.0) minutes, including all other procedures. These additional procedures included broviac placements 4 of 15 (26.7%), tracheoesophageal fistula repair 1 of 15 (6.7%), Ladd's procedure 3 of 15 (20.0%), and removal of gastric foreign body 1 of 15 (6.7%) (Table 2).
Operative Characteristics
Median (range).
FB, foreign body; TEF, tracheoesophageal fistula.
With regard to complications, 1 patient required reoperation with anastomotic revision for stenosis. One patient developed an intraoperative enterotomy in the first portion of the duodenum from a traction stitch, this was immediately identified and repaired laparoscopically. There was one operation that was converted from laparoscopic to open because of difficulties mobilizing the third portion of the duodenum, and 1 patient had an anastomotic leak. For the patient with the anastomotic leak, an esophagram was performed 1 week postoperatively to evaluate the concurrent tracheoesophageal fistula repair, which incidentally showed a small duodenal anastomotic leak. As the patient did not show clinical evidence of leak, management included nasogastric decompression and antibiotics. A repeat contrast study after 12 days demonstrated no leak. Otherwise, there were no anastomotic leaks requiring reoperation, blood transfusions, or deaths. The median time to full enteral feeds was 15 (11–20) days, the median length of stay was 24 (14–36) days, and the median length of time of the ventilator was 2 (0.5–3) days (Table 3).
Outcomes
Median (range).
Discussion
The proposed advantages of laparoscopic repair include improved cosmesis and shorter recovery times. In addition, the study by Spilde et al. demonstrated a decreased length of stay and shorter time to enteral feeds with laparoscopic compared with open repair. 3 Compared with previous studies examining laparoscopic duodenoduodenostomy, our median time of 15 days to full enteral falls within previously published range of 9 to 36 days.3–6 Despite these benefits, a study by van der Zee raised concerns regarding the safety of laparoscopic duodenal atresia repair, specifically regarding increased rates of anastomotic leaks. 7 Performing laparoscopic repair of congenital duodenal obstruction is a technically challenging procedure, and an increased risk for anastomotic leak or stenosis has been reported. 7 In our reported case series of 15 patients wherein laparoscopic repair was completed in 14 of 15 (93.3%) patients, we used a diamond-shaped anastomosis, with a running suture in the posterior wall and interrupted sutures in the anterior wall to complete the anastomosis and did not have any anastomotic leaks requiring reoperation. Similar to other series, only 1 patient developed an anastomotic stricture.3,4,6 This patient was one of the first patients operated on in this series, which might be reflective of a learning curve for performing this operation. The conversion rate to open surgery in our series was also much lower than the previously reported 35% rate. 4
Intracorporeal suturing can be performed effectively and safely in neonates.3,5 There has been some discussion whether running versus interrupted sutures lead to improved anastomotic outcomes. 7 Similarly, other studies have reported excellent outcomes when creating a duodenoduodenostomy with either interrupted or running suture. 5
Limitations of this study include its retrospective nature and small size. In addition, there may have been selection bias to include only the best laparoscopic candidates for laparoscopic surgery. However, comparing the number of laparoscopic cases to open cases performed during the same time by the operating surgeon, this bias is unlikely. Factors that affect patient selection include birth weight, presence of other congenital anomalies (specifically cardiac disease), and presence of malrotation. Evaluating our patient selection, the operating surgeon performed a total of 19 duodenoduodenostomies between 2010 and 2017 of which 15 of 19 (78.9%) were attempted laparoscopically. The reason for open repair in the remaining 4 patients were perforation on presentation (n = 1), concern for ischemic bowel (n = 1), and presence of omphalocele (n = 1). It is reasonable to suggest our results are generalizable to most neonates with congenital duodenal obstruction since we performed the operation in patients with abnormal intestinal rotation as well as an infant weighting only 1.5 kg.
In conclusion, laparoscopic duodenoduodenostomy is an operation that can be performed with excellent outcomes following simple steps that are easily taught in a teaching setting.
Footnotes
Disclosure Statement
No competing financial interests exist.