Simple incision: A safe and definitive procedure for congenital duodenal diaphragm

CASE REPORTS

Simple Incision:

A Safe and Definitive Procedure Duodenal Diaphragm By M. Zia-ul-Miraj,

Background: Duodenal diaphragms generally are either a duodeno-duodenostomy or excision. The bypass procedure that involves a major anastomosis inherent postoperative problems, whereas the result in inadvertent damage to the biliary and ducts. To circumvent these problems, the authors technique of incision of the diaphragm on its lateral Methods: Medical records of five surgery for a perforate duodenal period of 1992 through 1994 were All patients underwent a similar duodenotomy was made and the anterolateral aspect. The cut edges

N.l? Madden, and R.J. Breretont London, England

treated by former is a with its latter may pancreatic used the aspect.

children who underwent diaphragm during the reviewed retrospectively. procedure. A longitudinal diaphragm incised on its of the diaphragm were

D

UODENAL DIAPHRAGM (DD) is an uncommon anomaly, with a reported incidence varying from 1 in 10,000 to 40,000 live births.‘-” A complete diaphragm generally is classified as type 1 duodenal atresia (DA), whereas a perforate diaphragm is graded as a subtype of another category of DA termed as duodenal stenosis. 1,4-6 During the past 50 years, there has been a gradual fall in the mortality rate associated with doudenal atresia, principally as a result of antenatal diagnosis, prompt intervention, improved anaesthesia and intensive therapy, and modification of surgical techniques.3,4 However, a few controversies still persist. One of these controversies centers around the optimal surgical procedure for a DD, to reduce the immediate and late postoperative complication rate. There are two main surgical approaches to treat a DD: one involving a bypass procedure like gastrojejunostomy, duodeno-jejunostomy or duodeno-duodenostomy. and the other, a direct procedure like excision or incision of the diaphragm. We describe our experience with the technique of simple incision of DD, along with a literature review. MATERIALS

AND

METHODS

Five patients underwent surgery for a perforate duodenal diaphragm durmg the penod from 1992 through 1994. Their clinical details are outlined in Table 1. Upper gastrointestinal contrast studies m these patients showed evidence of a perforate DD (Rg 1) or incomplete duodenal obstruction (Fig 2). It is worth noting that four of our five patients presented beyond the neonatal period. All patients underwent a Journa/ofPediafricSurgery,Vol34,

No 6 (June),

for Congenital

1999: pp 1021-1024

oversewn, licz”fashion.

and

the

Resu/ts:At are growing symptoms.

a follow-up normally

duodenotomy

ranging from and remain

closed

in “Heineke-Miku-

1 to 3 years, free of any

all patients obstructive

Conc/usions:This simplified approach is a safe and physiological way of restoring the duodenal continuity and is associated with a highly satisfactory outcome. J Pediatr Surg 34:1021-7024. Copyrighr o 7999 by W.B. Saunders Company. INDEX phragm.

WORDS:

Duodenal

atresia,

congenital

duodenal

dia-

sirmlar surgical procedure. The abdomen was opened through a right supraumbilical transverse incision. The hepatic flexure was displaced downward and medially and the duodenum moblhzed by Kocher’s maneuvre. A longitudinal anterolateral duodenotomy was made across the site of attachment of DD that was evident externally by a slight indentation of the serosal surface of the duodenum. DD was Identified (Fig 3) and, with the help of electrocautry, an incision made across its anterolateral aspect extending up to the aperture. The medial edge of the chaphragm and the medial rim of its aperture were left undisturbed. The raw edges of the incised diaphragm retracted immediately and were oversewn with fine absorbable stitches (Fig 4). After excluding any addmona diaphragm proximally or distally, the duodenotomy was closed transversely in “Heineke-Mikulicz” fashion. No gastrostomy or transanastomatic tube was left.

RESULTS

There was no immediate postoperative complication. The postoperative hospital stay was 10 days in the neonate (case l), 9 days in the infant (case 2), and 6 to 7 days in older children (cases 3, 4, and 5). Follow-up ranged from 1 to 3 years. All the five patients are growing normally and remain free of any obstructive symptoms.

From the Departtuerlt of Paedmtric Surgery, Chelsea and Westminster Hospital, London, UK. fDeceased. Address reprint requests to M. Zia-ul-Miraj, FRCS, DCH, D Paed Surg, D Ural, 86-S, Model Town Extension, Lahore, Pakistan. Copyright o 1999 by WB. Saunders Company 0022-3468/99/3406-0021$03.00/O 1021

ZIA-UL-MIRAJ,

1022

Table Patient

NO.

1. Clinical

Details

of the Patients

With

Duodenal

Age

Chcal

Features

ofDD

Intermittent vomiting since birth, Upper GI contrast: perforate DD (Frg I)

2nd part

2

3mo

2nd part

Incision

of DD

disease Midgut malrotation

3

Female 19mo

Intermittent vomiting since birth, Upper GI contrast: perforate DD Intermittent vomiting since 6 mo, pro-

4th part

lncrsron

of DD

NII

2nd part

Incision

of DD

Nil

Male

Intermittent vomiting since 8 mo, Upper GI contrast: perforate DD

3 Yr Female

Intermittent vomiting since birth, gradually becoming more frequent and

2nd part

Incision of DD (Figs 3,4)

Male

gressively

getting

worse,

forceful, often containing food, epigastricfullness,

BRERETON

Associated Anomalies

Procedure

23d Male

1

AND

Diaphragm

Site

SC?X

MADDEN,

Incision

of DD

Down’s septal

syndrome, defect,

Ventricular Hirschsprung’s

becoming undigested FB (screw)

lodged in the duodenum, Upper GI contrast: huge duodenum, intrinsic incomplete obstruction 4 5

2v

forceful,

postprandral

tric fullness, GI contrast: Abbreviations:

Upper

GI contrast,

(DD) (Fig 2)

upper

bloating,

epigas-

succussion splash, perforate DD gastrointestinal

Down’s syndrome, Patent ductus arteriosus, Ventricular septal defect

Upper

contrast

study;

DISCUSSION

There are two main surgical approaches to dealing with a DD: first, a bypass procedure and second, a direct approach. The bypass procedures, like gastrojejunostomy and doudenojejunostomy, are no longer practiced because they are associated with a high incidence of postoperative complications including stoma1 ulceration and blind-loop syndrome .3,7.8Duodeno-duodenostomy, with either a side-to-side or “diamond-shaped” anastomosis, is the most commonly practiced bypass procedure.2.3,9-i3 However, again, it is an unphysiological procedure that always leaves the possibility of long-term problem of “wind-sock” phenomenon because the diaphragm is left intact.14 In addition, there is always a risk

Fig 1. Case 1. Upper gastrointestinal contrast study shows a duodenal diaphragm with a small aperture through which contrast can be seen entering into the distal part of the duodenum (arrow).

FB, foreign

body.

of performing the anastomosis at the wrong side of the diaphragm. l5 Spigland and Yazbecks found a high incidence of complications, reoperation rate, and delayed reestablishment of bowel transit after bypass procedures

Fig 2. Case 3. Upper gastrointestinal contrast study hugely distended duodenum. The condition was brought to by a retained foreign body, a screw (arrow), that failed to beyond the duodenal area. During surgery, a perforate diaphragm was found in the fourth part of the duodenum.

shows a attention progress duodenal

SIMPLE

INCISION

FOR CONGENITAL

DUODENAL

DIAPHRAGM

1023

Fig 3. Case 5. A perforate duodenal diaphragm visible through a duodenotomy. Note the forceps traversing the aperture in the diaphragm.

compared with the technique of web excision combined with a duodenoplasty. The direct approaches to the diaphragm include open excision (complete or partial) or incision through a

Fig 4. The raw prominent

Same patient as in Fig 3. The diaphragm edge has been oversewn and appears mucosal fold (arrows).

has been no more

incised. than a

duodenotomy and endoscopic resection. Although successful endoscopic electrosurgical and laser ablation of DD has been performed in adults and older children, its routine use is limited by lack of experience in the neonates and infants and its potential complications like duodenal perforation.16J7 Excision of DD is the most favored direct surgical approach. 1.3,468.1*-22However, because of the close proximity of the ampulla of Vater, common bile duct, or an accessary pancreatic duct, there always is an increased risk of damage to these structures during the excision of DD.15 In view of these problems inherent in excision, we prefer a simple incision of the lateral aspect of DD extending up to its aperture. As in most cases, the ampulla is sited in the medial duodenal wall adjacent to DD or in the medial rim of the aperture; DD can safely be incised along the lateral side, leaving the medial edge undisturbed.a.23 We have observed that because the DD is always under some tension, the cut edges retract immediately, and after having been oversewn. look no more than a prominent mucosal fold (Fig 4). In addition, because the aperture usually is eccentric and near the medial duodenal wa11,3there is no actual risk of an obstructing shelf to be left. Above all, the duodenal continuity is further ascertained by closure of the duodenotomy in HeinekeMikulicz fashion. Compared with the procedure involving an excision of DD, this approach is easy, simple, and involves a high degree of safety in terms of protection of the Vaterian ampulla because the medial edge is left intact. At the same time, because it helps avoid a major anastomosis, it shares the advantages of the former procedure, including a more rapid restoration of the bowel transit and a low incidence of postoperative complications compared with the bypass procedures. We used this technique in five patients and found it highly satisfactory. This direct approach is more physiological because it leads to reestablishment of the duodenal continuity by the simplest and most appropriate means that also restores a near-normal anatomy.

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AND

BRERETON

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