Endoscopic membranectomy of duodenal diaphragm: pediatric experience

Endoscopic membranectomy of duodenal diaphragm: pediatric experience Filippo Torroni, MD, Paola De Angelis, MD, Tamara Caldaro, MD, Giovanni Federici di Abriola, MD, Antonio Ponticelli, MD, Gianluca Bergami, MD, Luigi Dall’Oglio, MD Rome, Italy

Duodenal diaphragms (DD) are an intrinsic cause of partial duodenal obstruction.1-3 Intermittent vomiting, sometimes bilious, is often the main presenting symptom. In adults, the primary treatment consists of endoscopic membranectomy; children often undergo surgical therapy. Endoscopic therapy for infants has been described previously.4 We report our use of endoscopic therapy in 4 pediatric patients with DD.

CASE REPORTS Between 1989 and 2001, we attempted endoscopic treatment in four children with DD whose clinical characteristics are listed in Table 1. Esophagoduodenoscopy (Olympus GIFXP20, GIF100; Olympus Optical Co [Europa], Hamburg, Germany) was performed with the patients under general anesthesia. In 3 patients, endoscopic membranectomy was performed with a standard 5F sphincterotome. An incision of the DD was made, allowing advancement of the endoscope into the distal duodenum (Figs. 1A and B). Postoperative upper GI x-rays showed complete resolution of the partial obstruction seen before therapy (Figs. 2A and B). No early or late complications occurred. Therapy in one patient was not possible due to an inability to reach the diaphragm with the upper endoscope; this patient had had previous surgery for annular pancreas.

DISCUSSION In pediatric patients, endoscopic membranectomy for DD with a sphincterotome appears to provide rapid, effective and safe resolution of the obstruction and avoids the long hospitalization and complications related to surgery.

Figure 1. A, Medial incision of duodenal diaphragm with sphincterotome. B, Results of incision.

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Figure 2. A, Upper GI x-ray before endoscopic therapy. B, Upper GI x-ray after endoscopic membranectomy in the same patient.

TABLE 1. Patients’ characteristics Patient (sex) Characteristic Age at surgery

1 (M) 34 months

2 (F)

3 (F)

8 days

4 months

Prenatal history

4 (M) 66 months

Polyhydramnios; premature birth

Associated anomalies

Annular pancreas

Type of DD

Perforated diaphragm

Perforated diaphragm

Perforated diaphragm

Perforated diaphragm

Location of DD

3rd segment

Treitz ligament

Treitz ligament

Treitz ligament

Presentation

Recurrent vomiting

Bilious vomiting

Recurrent vomiting

Recurrent vomiting

Procedure

Incision with papillotome

Incision with papillotome

Incision with papillotome

REFERENCES 1. Zia-ul Miraj M, Madden NP, Brereton RJ. Simple incision: a safe and definitive procedure for congenital duodenal diaphragm. J Pediatr Surg 1999;34:1021-4. 2. Monga R, Tyagi P, Garg S, Puri AS. Endoscopic management of multiple duodenal diaphragm: case report. Gastrointest Endosc 2003;58: 158-60. 3. Menardi G. Duodenal atresia, stenosis and annular pancreas. In: Freeman NV, Burge DM, Griffith M, et al, editors. Surgery of the newborn. 1st ed. Edinburgh, Scotland: Churchill Livingstone; 1994. p. 107-15.

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4. Okamatsu T, Arai K, Yatsuzuka M, et al. Endoscopic membranectomy for congenital duodenal stenosis in a infant. J Pediatr Surg 1989;24:367-8. Current affiliation: Surgical and Endoscopic Digestive Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy. Reprint requests: Luigi Dall’Oglio, MD, Ospedale Pediatrico Bambino Gesu`, Piazza S. Onofrio, 400165 Roma, Italy. Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2005.10.001

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