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Diamond-shaped anastomosis for duodenal atresia: An experience with 44 patients over 15 years
Diamond-Shaped Anastomosis for Duodenal Atresia: An Experience With 44 Patients Over 15 Years By Ken Kimura,
Nobuhiko
Mukohara,
Eiji Nishijima,
Toshihiro
Muraji,
Chikara Tsugawa,
and Yoichi Matsumoto
Kobe, Japan 0 During the period between 1974 and 1988,44 patients were treated for congenital intrinsic duodenal obstruction using a diamond-shaped anastomosis (35 atresias. including two multiple atresias and nine stenoses). Neither gastrostomy nor transanstomotic tube was used. Postoperatively, oral feeding was started on days 2 to 6 (3.66 f 1 Al day). Intravenous fluid administration was discontinued on days 3 to 20 (7.64 k 3.68 day). Fourteen patients died, none related to the operative procedure. Of 30 survivors, 21 patients have been followed from 6 months to 15 years. Body weight was within the normal range at the latest visit. Current barium study performed in 19 patients showed no blind loop, megaduodenum, or anastomotic malfunction. The diamond-shaped anastomosis provides the following advantages: (I) early recovery of anastomotic function, and (2) avoidance of later complications, such as formation of a blind loop or anastomotic stenosis. 0 1990 by W. B. Saunders Company. INDEX WORDS:
Duodenal atresia.
I
N MANAGING patients with duodenal atresia or stenosis, anastomotic malfunction often requires prolonged intravenous nutritional care and hospitalization, which in turn is closely related to the design of the anastomotic technique.’ In 1977, we introduced an anastomotic technique of duodenoduodenostomy, arranging the bowel incisions to form a “diamond shape” that creates a larger stoma.2 With this technique, the anastomosis recovered its function in a significantly shorter time period compared with other forms of anastomosis.’ This report describes technically important points in this anastomosis and reviews results regarding long-term anastomotic function. MATERIALS
AND
METHODS
From 1974 to 1988, 44 children (21 boys and 23 girls) were treated for congenital intrinsic duodenal obstruction using a diamondshaped anastomosis. At the time of surgery, 42 patients were 1 to 28 days of age (mean, 4.4 + 4.1 days; range, 1 to 15 days; n = 39), and two were 8 months and 4 years of age (congenital duodenal stenosis and unsuccessful duodenojejunostomy, respectively). Thirty-three patients presented with single atresia, nine with stenosis, and two with multiple atresias. Eighteen patients (40%) had an associated annular pancreas. Twenty-four patients (55%) had associated major anomalies. Operative
Technique
After entering the abdomen, the duodenum is adequately mobilized by Kocher maneuver. The ligament of Treitz is divided as needed.’ With two traction sutures, the redundant wall of the proximal duodenum is brought down to overlie the proximal portion of the distal duodenal segment; if this cannot be done easily, more mobilization of the megaduodenum is needed (Fig 1A). A mixture of Journal of Pediatric Surgery, Vol 25, No 9 /September),
1990: pp 977-979
air and saline is injected into the distal bowel lumen to rule out downstream atresias; the distal duodenum can be distended to a larger size during this maneuver by gently occluding the proximal jejunum either by the surgeon’s finger or an intestinal clamp. A transverse incision in the distal end of the proximal duodenum and a longitudinal incision in the distal duodenum are made of the same length. The papilla of Vater is located by observing bile flow. This is performed by gentle compression of the gall bladder. Using 5-O or 6-O catgut or Vicryl continuous inner and 6-O silk interrupted outer layer sutures, a double layer anastomosis is completed (Fig 1B). No gastrostomy or transanastomotic tube is used. The duodenoduodenostomy achieved by this technique takes the shape of a diamond’ (Fig IC).
immediate Postoperative Management The stomach is continuously emptied by gravity drainage, using an 8F to 10F nasogastric tube. When upright abdominal films show that gas is distributed in the distal intestine, the nasogastric tube is clamped and intermittently (every 2 hours) opened to aspirate and measure the gastric residual. When the gastric residual is less than 20 mL, oral feedings are started with 30 mL of regular formula, which is subsequently increased as tolerated.J
Long-Range Follow-Up The patients were recalled 6 months to 15 years after surgery. In 19 patients who responded, the mode of diet and body weight were recorded and an upper gastrointestinal contrast study was performed. RESULTS Postoperative oral feedings were started on days 2 to 6 (mean, 3.66 + 1.41 days). Intravenous fluid administration was discontinued on days 3 to 20 (mean, 7.54 f 3.58 days) when an adequate amount of oral feeding was tolerated. Fourteen patients died; five died within 30 days of surgery of pneumonia and sepsis, and nine late deaths were related to associated anomalies. None of the deaths was related to the duodenal anastomotic procedure. Of 30 survivors, 21 patients were followed from 6 months to 15 years. All patients were free from gastrointestinal symptoms. Body weight
From the Department of Surgery, Kobe Children’s Hospital, Kobe. Japan. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October .21-23,1989. Address reprint requests to Ken Kimura, MD, Department of Surgery, The University of Iowa College of Medicine, Iowa City, IA 52242. 0 1990 by W.B. Saunders Company. 0022-3468/90/2509-0011$03.00/0
977
KIMURA
Fig 1.
was within the normal range at the latest visit. Current barium studies performed in 19 patients showed no blind loop, megaduodenum formation, or anastomotic malfunction. DISCUSSION
An extensive survey by Fonkalsrud et al’ in 1969 reported a mortality rate of 32% in patients with duodenal atresia, half of which were related to anastomotic complications. In their report, the majority of patients were treated by duodenojejunostomy, which was the standard technique at that time.6 In the 1960s to 1970s surgeons came to advocate duodenoduodenostomy more commonly, finding relatively earlier recovery of anastomotic function.3*7-‘1 Reviewing the descriptions in previous reports, we recognized that the bowel
ET AL
Diamond-shaped anastomosis.
incisions were arranged in parallel fashion when either duodenojejunostomy or duodenoduodenostomy was of performed. “Jo We considered that this arrangement bowel incisions may have contributed to delayed recovery of anastomotic function. In contrast, the diamondshaped anastomosis is fashioned by approximating the end of one incision to the appropriate midportion of the other incision, to provide a larger stoma. Another significant point in this technique is the extensive dissection of the proximal duodenum in order to bring it down to overlie the distal duodenum. By this procedure, substantial reduction of the overhanging redundant duodenal wall is achieved, which may serve to eliminate persistent duodenal stasis. The location of bowel incisions at the closest points to the atresia is of technical importance to avoid formation of a blind
DIAMOND-SHAPED
979
ANASTOMOSIS
loop. I4 During
the procedure, the entire bowel from the duodenum to the rectum was moderately inflated by intraluminally injected air, which seemed to stimulate postoperative bowel motility and early recovery of bowel function. The relatively high mortality rate encountered in the early patients was mainly related to the complications of associated anomalies. Today, this would be improved by better neonatal intensive care, especially respiratory and nutritional support.’ A recent report on the long-term results of newborns with duodenal atresia by Kokkonen et al” warned us of the importance of continuous observation of the patients over years. In their series, growth and develop-
ment including body weight were satisfactory. However, persistant abnormal morphology of the duodenum at the anastomosis was found by contrast studies in their late follow-up. In contrast, barium studies in the patients in this series showed satisfactory passage of contrast material through the anastomosed portion of the duodenum with less deformed configuration, suggesting that our technique preserves a more natural anatomical configuration to the reconstructed duodenum. ACKNOWLEDGMENT The authors thank Dr Robert T. Soper for his assistance in preparing the manuscript.
REFERENCES 1. Weber TR, Lewis JE, Mooney D, et al: Duodenal atresia: A comparison of techniques of repair. J Pediatr Surg 21:1133-l 136, 1986 2. Kimura K, Tsugawa C, Ogawa K, et al: Diamond-shaped anastomosis for congenital duodenal obstruction. Arch Surg 112: 1262-1263,1977 3. Weitzman JJ, Prennon LP: An improved technique for the correction of congenital duodenal obstruction in the neonates. J Pediatr Surg 9:385-388, 1974 4. Wakayama Y, Wilkins S, Kimura K: Is 5% dextrose in water a proper choice for initial postoperative feeding in infants? J Pediatr Surg 22~644-646, 1988 5. Fonkalsrud EW, deLorimier AA, Hays DM: Congenital atresia and stenosis of the duodenum. Pediatrics 43:79-83, 1969 6. Gross RE: The Surgery of Infancy and Childhood: Its Principles and Techniques. Philadelphia, PA, Saunders, 1953, pp 150-166 7. Girvan DP, Stephens DA: Congenital intrinsic duodenal obstruction: A twenty-year review of its surgical management and consequence. J Pediatr Surg 9:833-839, 1974
8. Wayne ER, Burrington JD: Management of 97 children with duodenal obstruction. Arch Surg 107:857-861, 1973 9. Feuchtwanger MM, Weiss Y: Side-to-side duodenoduodenostomy for obstructing annular pancreas in the new born. J Pediatr Surg 3:398-401, 1968 10. Stauffer UG, Irving I: Duodenal atresia and stenosis. Long term results. Prog Pediatr Surg 10:49-58, 1977 11. Wesley JR, Mahour GH: Congenital intrinsic duodenal obstruction: A twenty-five years review. Surgery 82:716-720, 1977 12. Rickham PP: Duodenal atresia and stenosis, in Rickham PP, Johnson JH (eds): Neonatal Surgery. London, England, Butterworth, 1969, pp 286-302 13. Schnaufer L: Duodenal atresia, stenosis and annular pancreas, in Welch KJ, Randolf JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1986, pp 829-837 14. Ein SH, Shandling B: The late nonfunctioning duodenal atresia. J Pediatr Surg 21:798-801, 1986 15. Kokkonen ML, Kalima T, Jaaskelainen J, et al: Duodenal atresia: Late follow-up. J Pediatr Surg 23:216-220, 1988
Discussion M. Abrams (New York, NY): Were there any anastomotic leaks or difficulties that might have related at all to the mortalities?
K. Kimura (response): No. None of the patients’ deaths were related to anastomotic complications. I didn’t observe leakage.
Nobuhiko
Mukohara,
Eiji Nishijima,
Toshihiro
Muraji,
Chikara Tsugawa,
and Yoichi Matsumoto
Kobe, Japan 0 During the period between 1974 and 1988,44 patients were treated for congenital intrinsic duodenal obstruction using a diamond-shaped anastomosis (35 atresias. including two multiple atresias and nine stenoses). Neither gastrostomy nor transanstomotic tube was used. Postoperatively, oral feeding was started on days 2 to 6 (3.66 f 1 Al day). Intravenous fluid administration was discontinued on days 3 to 20 (7.64 k 3.68 day). Fourteen patients died, none related to the operative procedure. Of 30 survivors, 21 patients have been followed from 6 months to 15 years. Body weight was within the normal range at the latest visit. Current barium study performed in 19 patients showed no blind loop, megaduodenum, or anastomotic malfunction. The diamond-shaped anastomosis provides the following advantages: (I) early recovery of anastomotic function, and (2) avoidance of later complications, such as formation of a blind loop or anastomotic stenosis. 0 1990 by W. B. Saunders Company. INDEX WORDS:
Duodenal atresia.
I
N MANAGING patients with duodenal atresia or stenosis, anastomotic malfunction often requires prolonged intravenous nutritional care and hospitalization, which in turn is closely related to the design of the anastomotic technique.’ In 1977, we introduced an anastomotic technique of duodenoduodenostomy, arranging the bowel incisions to form a “diamond shape” that creates a larger stoma.2 With this technique, the anastomosis recovered its function in a significantly shorter time period compared with other forms of anastomosis.’ This report describes technically important points in this anastomosis and reviews results regarding long-term anastomotic function. MATERIALS
AND
METHODS
From 1974 to 1988, 44 children (21 boys and 23 girls) were treated for congenital intrinsic duodenal obstruction using a diamondshaped anastomosis. At the time of surgery, 42 patients were 1 to 28 days of age (mean, 4.4 + 4.1 days; range, 1 to 15 days; n = 39), and two were 8 months and 4 years of age (congenital duodenal stenosis and unsuccessful duodenojejunostomy, respectively). Thirty-three patients presented with single atresia, nine with stenosis, and two with multiple atresias. Eighteen patients (40%) had an associated annular pancreas. Twenty-four patients (55%) had associated major anomalies. Operative
Technique
After entering the abdomen, the duodenum is adequately mobilized by Kocher maneuver. The ligament of Treitz is divided as needed.’ With two traction sutures, the redundant wall of the proximal duodenum is brought down to overlie the proximal portion of the distal duodenal segment; if this cannot be done easily, more mobilization of the megaduodenum is needed (Fig 1A). A mixture of Journal of Pediatric Surgery, Vol 25, No 9 /September),
1990: pp 977-979
air and saline is injected into the distal bowel lumen to rule out downstream atresias; the distal duodenum can be distended to a larger size during this maneuver by gently occluding the proximal jejunum either by the surgeon’s finger or an intestinal clamp. A transverse incision in the distal end of the proximal duodenum and a longitudinal incision in the distal duodenum are made of the same length. The papilla of Vater is located by observing bile flow. This is performed by gentle compression of the gall bladder. Using 5-O or 6-O catgut or Vicryl continuous inner and 6-O silk interrupted outer layer sutures, a double layer anastomosis is completed (Fig 1B). No gastrostomy or transanastomotic tube is used. The duodenoduodenostomy achieved by this technique takes the shape of a diamond’ (Fig IC).
immediate Postoperative Management The stomach is continuously emptied by gravity drainage, using an 8F to 10F nasogastric tube. When upright abdominal films show that gas is distributed in the distal intestine, the nasogastric tube is clamped and intermittently (every 2 hours) opened to aspirate and measure the gastric residual. When the gastric residual is less than 20 mL, oral feedings are started with 30 mL of regular formula, which is subsequently increased as tolerated.J
Long-Range Follow-Up The patients were recalled 6 months to 15 years after surgery. In 19 patients who responded, the mode of diet and body weight were recorded and an upper gastrointestinal contrast study was performed. RESULTS Postoperative oral feedings were started on days 2 to 6 (mean, 3.66 + 1.41 days). Intravenous fluid administration was discontinued on days 3 to 20 (mean, 7.54 f 3.58 days) when an adequate amount of oral feeding was tolerated. Fourteen patients died; five died within 30 days of surgery of pneumonia and sepsis, and nine late deaths were related to associated anomalies. None of the deaths was related to the duodenal anastomotic procedure. Of 30 survivors, 21 patients were followed from 6 months to 15 years. All patients were free from gastrointestinal symptoms. Body weight
From the Department of Surgery, Kobe Children’s Hospital, Kobe. Japan. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October .21-23,1989. Address reprint requests to Ken Kimura, MD, Department of Surgery, The University of Iowa College of Medicine, Iowa City, IA 52242. 0 1990 by W.B. Saunders Company. 0022-3468/90/2509-0011$03.00/0
977
KIMURA
Fig 1.
was within the normal range at the latest visit. Current barium studies performed in 19 patients showed no blind loop, megaduodenum formation, or anastomotic malfunction. DISCUSSION
An extensive survey by Fonkalsrud et al’ in 1969 reported a mortality rate of 32% in patients with duodenal atresia, half of which were related to anastomotic complications. In their report, the majority of patients were treated by duodenojejunostomy, which was the standard technique at that time.6 In the 1960s to 1970s surgeons came to advocate duodenoduodenostomy more commonly, finding relatively earlier recovery of anastomotic function.3*7-‘1 Reviewing the descriptions in previous reports, we recognized that the bowel
ET AL
Diamond-shaped anastomosis.
incisions were arranged in parallel fashion when either duodenojejunostomy or duodenoduodenostomy was of performed. “Jo We considered that this arrangement bowel incisions may have contributed to delayed recovery of anastomotic function. In contrast, the diamondshaped anastomosis is fashioned by approximating the end of one incision to the appropriate midportion of the other incision, to provide a larger stoma. Another significant point in this technique is the extensive dissection of the proximal duodenum in order to bring it down to overlie the distal duodenum. By this procedure, substantial reduction of the overhanging redundant duodenal wall is achieved, which may serve to eliminate persistent duodenal stasis. The location of bowel incisions at the closest points to the atresia is of technical importance to avoid formation of a blind
DIAMOND-SHAPED
979
ANASTOMOSIS
loop. I4 During
the procedure, the entire bowel from the duodenum to the rectum was moderately inflated by intraluminally injected air, which seemed to stimulate postoperative bowel motility and early recovery of bowel function. The relatively high mortality rate encountered in the early patients was mainly related to the complications of associated anomalies. Today, this would be improved by better neonatal intensive care, especially respiratory and nutritional support.’ A recent report on the long-term results of newborns with duodenal atresia by Kokkonen et al” warned us of the importance of continuous observation of the patients over years. In their series, growth and develop-
ment including body weight were satisfactory. However, persistant abnormal morphology of the duodenum at the anastomosis was found by contrast studies in their late follow-up. In contrast, barium studies in the patients in this series showed satisfactory passage of contrast material through the anastomosed portion of the duodenum with less deformed configuration, suggesting that our technique preserves a more natural anatomical configuration to the reconstructed duodenum. ACKNOWLEDGMENT The authors thank Dr Robert T. Soper for his assistance in preparing the manuscript.
REFERENCES 1. Weber TR, Lewis JE, Mooney D, et al: Duodenal atresia: A comparison of techniques of repair. J Pediatr Surg 21:1133-l 136, 1986 2. Kimura K, Tsugawa C, Ogawa K, et al: Diamond-shaped anastomosis for congenital duodenal obstruction. Arch Surg 112: 1262-1263,1977 3. Weitzman JJ, Prennon LP: An improved technique for the correction of congenital duodenal obstruction in the neonates. J Pediatr Surg 9:385-388, 1974 4. Wakayama Y, Wilkins S, Kimura K: Is 5% dextrose in water a proper choice for initial postoperative feeding in infants? J Pediatr Surg 22~644-646, 1988 5. Fonkalsrud EW, deLorimier AA, Hays DM: Congenital atresia and stenosis of the duodenum. Pediatrics 43:79-83, 1969 6. Gross RE: The Surgery of Infancy and Childhood: Its Principles and Techniques. Philadelphia, PA, Saunders, 1953, pp 150-166 7. Girvan DP, Stephens DA: Congenital intrinsic duodenal obstruction: A twenty-year review of its surgical management and consequence. J Pediatr Surg 9:833-839, 1974
8. Wayne ER, Burrington JD: Management of 97 children with duodenal obstruction. Arch Surg 107:857-861, 1973 9. Feuchtwanger MM, Weiss Y: Side-to-side duodenoduodenostomy for obstructing annular pancreas in the new born. J Pediatr Surg 3:398-401, 1968 10. Stauffer UG, Irving I: Duodenal atresia and stenosis. Long term results. Prog Pediatr Surg 10:49-58, 1977 11. Wesley JR, Mahour GH: Congenital intrinsic duodenal obstruction: A twenty-five years review. Surgery 82:716-720, 1977 12. Rickham PP: Duodenal atresia and stenosis, in Rickham PP, Johnson JH (eds): Neonatal Surgery. London, England, Butterworth, 1969, pp 286-302 13. Schnaufer L: Duodenal atresia, stenosis and annular pancreas, in Welch KJ, Randolf JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1986, pp 829-837 14. Ein SH, Shandling B: The late nonfunctioning duodenal atresia. J Pediatr Surg 21:798-801, 1986 15. Kokkonen ML, Kalima T, Jaaskelainen J, et al: Duodenal atresia: Late follow-up. J Pediatr Surg 23:216-220, 1988
Discussion M. Abrams (New York, NY): Were there any anastomotic leaks or difficulties that might have related at all to the mortalities?
K. Kimura (response): No. None of the patients’ deaths were related to anastomotic complications. I didn’t observe leakage.