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Operative correction of duodenomegaly
Operative Correction of Duodenomegaly By Joseph O. Sherman and Maurice Schulten
O N G E N I T A L S M A L L - B O W E L atresia is a relatively rare birth defect occurring in approximately one in every 20,000 births. When it does occur, the associated mortality is impressively high) Before 1950 it was said to be 91%. 2 With the advent of more prompt diagnosis and treatment and improved techniques of operative correction, recent surveys have shown better results. From 1952 to 1959, Benson I reported a mortality rate of 38% for all small-bowel atresias and stenosis. In a survey of the Surgical Section of the American Academy of Pediatrics covering the period from 1957 to 1967, the mortality rate for duodenal atresia or stenosis was 32%3; for jejunal lesions 42%; and for ileal lesions 35% 4 Although there has been a marked improvement in the reported survival rates, the loss of better than one third of these infants is still a grim figure. Both Louw s and White 6 agreed that it should be possible to salvage four of every five infants with these defects. The other 20% they consider to be victims of multiple congenital abnormalities. One of the more important postoperative complications of small-bowel atresia and stenosis is the so-called blind loop syndrome. 1'3'5 7 This problem is caused by the inability of a markedly dilated proximal intestinal segment to produce effective peristalsis thereby producing a functional bowel obstruction. s,7,s The result is persistent recurrent bilious vomiting, diarrhea, malnutrition, failure to thrive, and often death. This problem is well known and most surgeons agree that whenever possible, resection of the dilated proximal segment and end-to-end anastomosis is the treatment of choice.~'3's'6.~~ When the resection of the entire dilated proximal segment and end-to-end anastomosis is possible, as in distal jejunal and ileal lesions, the mortality is reduced to 10%-20%) However, when the stenosis or atresia is in the proximal jejunum or duodenum with duodenomegaly requiring duodenojejunostomy, jejunojejunostomy, or gastrojejunostomy without resection of the proximal segment, the mortality ranges from 40% to 60%. 9 One important reason for this higher mortality is the nonfunctional dilated duodenal segment which cannot be easily resected because of the proximity of the pancreas and c o m m o n bile duct. Retention of this segment with duodenojejunostomy, jejunojejunostomy or gastrojejunostomy can result in the blind loop syndrome and the complications associated with it. The purpose of this report is to present two cases of high-bowel obstruction and a possible operative approach to correct this problem.
C
From Northwestern University Medical School, Chicago, IlL, and The Children's Memorial Hospital, Chicago, HI. Address for reprint requests: Joseph O. Sherman, M.D., 2300 Children's Plaza, Chicago, HI. 60614. 9 1974 by Grune & Stratton, Inc.
Journal of Pediatric Surgery, Vol. 9, No. 4 (August), 1974
461
462
SHERMAN AND SCHULTEN
CASE REPORTS
Case 1 A 10-too-old female infant was admitted with a history of high jejunal atresia diagnosed soon after birth and treated by end-to-end duodenojejunostomy at another hospital. After discharge from the hospital she continued to have intermittent episodes of vomiting and diarrhea with failure to thrive (below the third percentile in weight for her age). In the 3 days prior to admission, she had been vomiting large amounts of bile and had become lethargic. Physical examination revealed a thin, lethargic dehydrated infant in no acute distress. She weighed 13 lb, 4 oz and was 28 inches in length. Vital signs were normal and stable. The abdomen was fiat and no masses were felt. The rest of the examination was within normal limits. After rehydration and correction of electrolyte imbalance, an upper gastrointestinal x-ray series was obtained revealing a dilated, poorly functioning duodenal loop. She was taken to the operating room where a stenotic duodenjejunostomy was revised. Postoperatively, she continued to drain large amounts of bile-stained fluid per nasogastric tube (300 500 ml per 24 hr) and attempts to remove the tube resulted in renewed vomiting. A repeat upper gastrointestinal x-ray series revealed a large, poorly functioning duodenal loop. Five weeks after the revision procedure, she was returned to the operating room where a longitudinal resection of 50~ 60~ of the anterior wall of the dilated duodenal loop from the pylorus to the ligament of Treitz was accomplished without difficulty (Fig. 1A). Ten days postoperatively, she was taking oral liquids. Twelve days after the operation, she was taking strained foods without difficulty. Three weeks postoperatively she was discharged home, tolerating all foods and gaining weight. Follow-up x-rays revealed an irregular but functioning duodenal loop. At 3 yr 2 mo of age she is in the 50th percentile for her weight for her age and is otherwise healthy.
Fig. I. Techniques for reducing diameter of dilated duodenum. (A) Resection of anterior wall. (B) Imbrication of anterior wall.
DUODENOMEGALY
463
Case 2 A 27-hr-old male infant was transferred when bile-stained emesis was noted and 200 cc of bilious material was aspirated from his stomach. Physical examination revealed a normal male newborn in no acute distress. He weighed 5 lb 12 oz and his vital signs were normal and stable. A b d o m i n a l x-rays revealed two large air fluid levels in the upper a b d o m e n . After stabilization, he was taken to the operating r o o m where exploration revealed a considerably dilated d u o d e n u m and proximal j e j u n u m secondary to a high-jejunal atresia and, distally, eight separate jejunal webs. Each web was removed t h r o u g h an enterotomy, and an end-to-end jejunojejunostomy was performed. Postoperatively he continued to drain large quantities of g a s t r o s t o m y drainage. A t t e m p t s at clamping the gastrostomy and feeding resulted in vomiting. A repeat x-ray series revealed an enlarged poorly functioning duodenal loop. After 4 wk o f total parenteral nutrition and failure to establish oral intake, he was returned to the operating room where the dilated duodenal segment was imbricated along its anterior border with interrupted 5-0 silk sutures from the pyloris to the ligament of Treitz to reduce the effective circumference by approximately 60~,, (Fig. IB). On the 15th postoperative day, feedings were started and progressed slowly until at 5 wk he was eating well and gaining weight. At 7 wk postoperative, he was discharged home. At 7 m o he was in the 10th percentile for weight for his age and tolerating all feedings well.
DISCUSSION
A greatly dilated segment of small bowel loses its ability to produce effective peristalsis as suggested by Louw ~ and Phelan s and proved by the experiments o f N i x o n . 7 In intestinal atresia and stenosis, resection of the proximal dilated segment is of the utmost importance for proper postoperative intestinal function. However, when the nonfunctional dilated segment is in the duodenum, as in high-jejunal and duodenal atresia or stenosis, resection is not technically feasible. It appears from our brief experience that longitudinal resection or imbrication of the dilated duodenal wall, thus reducing the effective diameter, may help to restore adequate peristaltic function and prevent the usual problems seen with duodenomegaly. Of the two procedures, longitudinal resection would seem to have the greatest potential for complications because of the long intestinal closure line and increased risk of leakage. If the invaginated duodenal wall resulting from imbrication does not interfere with peristalsis, it would seem to be the preferable procedure. Longitudinal resection and imbrication appeared to have worked equally well in the two cases presented. As far as we know, these are the only two patients in which this type of surgical approach has been applied to the problem. Further evaluation of these procedures is needed by us and others to determine their usefulness as an approach to the problem of nonfunctioning duodenomegaly. SUMMARY
Two cases of nonfunctioning postoperative duodenomegaly in infants are presented with a discussion of the complications associated with this problem. A new surgical approach of longitudinal resection or imbrication of the duodenal wall to reduce its effective diameter and thus restore peristaltic function is presented.
464
SHERMAN AND SCHULTEN
REFERENCES
I. Benson CD, Lloyd JR, Smith JD: Resection and primary anastomosis in the management of stenosis and atresia to the jejunum and ileum. Pediatrics 26:265, 1960 2. Evans CH: Atresias of the gastrointestinal tract, lnt Abstr Surg 92:1, 1951 3. Fonkalsrud EW, de Lorimer AA, Hays DM: Congenital atresia and stenosis of the duodenum. Pediatrics 43:79, 1969 4. deLorimer AA, Fonkalsrud EW, Hays DM: Congenital atresia and stenosis of the jejunum and ileum. Surgery 65:819, 1969 5. Louw JH: Resection and end-to-end anastomosis in the management of atresia and stenosis of the small bowel. Surgery 62:940, 1967 6. White JW: Effects of changing concepts
upon diagnosis and management of intestinal atresia. Am Surg 37:34, 1971 7. Nixon HH: An experimental study of propulsion in isolated small intestine and application to surgery in the newborn. Am Roy Coil Surg Engl 27:105, 1960 8. Phelan JT, Lemmer KE, McDonough KB: Jejunoileal atresia and stenosis. Surgery 46:430, 1959 9~ Brimblecombe FSW, More HD: Duodenal atresia and stenosis in infants. Ann Surg 172:991, 1970 10. Thomas CG: Jejunoplasty for the correction of jejunal atresia. Surg Gynecol Obstet 129:545, 1969 11. Louw JH: Congenital atresia and severe stenosis in the newborn. S Afr J Clin Sci 3:109, 1952
O N G E N I T A L S M A L L - B O W E L atresia is a relatively rare birth defect occurring in approximately one in every 20,000 births. When it does occur, the associated mortality is impressively high) Before 1950 it was said to be 91%. 2 With the advent of more prompt diagnosis and treatment and improved techniques of operative correction, recent surveys have shown better results. From 1952 to 1959, Benson I reported a mortality rate of 38% for all small-bowel atresias and stenosis. In a survey of the Surgical Section of the American Academy of Pediatrics covering the period from 1957 to 1967, the mortality rate for duodenal atresia or stenosis was 32%3; for jejunal lesions 42%; and for ileal lesions 35% 4 Although there has been a marked improvement in the reported survival rates, the loss of better than one third of these infants is still a grim figure. Both Louw s and White 6 agreed that it should be possible to salvage four of every five infants with these defects. The other 20% they consider to be victims of multiple congenital abnormalities. One of the more important postoperative complications of small-bowel atresia and stenosis is the so-called blind loop syndrome. 1'3'5 7 This problem is caused by the inability of a markedly dilated proximal intestinal segment to produce effective peristalsis thereby producing a functional bowel obstruction. s,7,s The result is persistent recurrent bilious vomiting, diarrhea, malnutrition, failure to thrive, and often death. This problem is well known and most surgeons agree that whenever possible, resection of the dilated proximal segment and end-to-end anastomosis is the treatment of choice.~'3's'6.~~ When the resection of the entire dilated proximal segment and end-to-end anastomosis is possible, as in distal jejunal and ileal lesions, the mortality is reduced to 10%-20%) However, when the stenosis or atresia is in the proximal jejunum or duodenum with duodenomegaly requiring duodenojejunostomy, jejunojejunostomy, or gastrojejunostomy without resection of the proximal segment, the mortality ranges from 40% to 60%. 9 One important reason for this higher mortality is the nonfunctional dilated duodenal segment which cannot be easily resected because of the proximity of the pancreas and c o m m o n bile duct. Retention of this segment with duodenojejunostomy, jejunojejunostomy or gastrojejunostomy can result in the blind loop syndrome and the complications associated with it. The purpose of this report is to present two cases of high-bowel obstruction and a possible operative approach to correct this problem.
C
From Northwestern University Medical School, Chicago, IlL, and The Children's Memorial Hospital, Chicago, HI. Address for reprint requests: Joseph O. Sherman, M.D., 2300 Children's Plaza, Chicago, HI. 60614. 9 1974 by Grune & Stratton, Inc.
Journal of Pediatric Surgery, Vol. 9, No. 4 (August), 1974
461
462
SHERMAN AND SCHULTEN
CASE REPORTS
Case 1 A 10-too-old female infant was admitted with a history of high jejunal atresia diagnosed soon after birth and treated by end-to-end duodenojejunostomy at another hospital. After discharge from the hospital she continued to have intermittent episodes of vomiting and diarrhea with failure to thrive (below the third percentile in weight for her age). In the 3 days prior to admission, she had been vomiting large amounts of bile and had become lethargic. Physical examination revealed a thin, lethargic dehydrated infant in no acute distress. She weighed 13 lb, 4 oz and was 28 inches in length. Vital signs were normal and stable. The abdomen was fiat and no masses were felt. The rest of the examination was within normal limits. After rehydration and correction of electrolyte imbalance, an upper gastrointestinal x-ray series was obtained revealing a dilated, poorly functioning duodenal loop. She was taken to the operating room where a stenotic duodenjejunostomy was revised. Postoperatively, she continued to drain large amounts of bile-stained fluid per nasogastric tube (300 500 ml per 24 hr) and attempts to remove the tube resulted in renewed vomiting. A repeat upper gastrointestinal x-ray series revealed a large, poorly functioning duodenal loop. Five weeks after the revision procedure, she was returned to the operating room where a longitudinal resection of 50~ 60~ of the anterior wall of the dilated duodenal loop from the pylorus to the ligament of Treitz was accomplished without difficulty (Fig. 1A). Ten days postoperatively, she was taking oral liquids. Twelve days after the operation, she was taking strained foods without difficulty. Three weeks postoperatively she was discharged home, tolerating all foods and gaining weight. Follow-up x-rays revealed an irregular but functioning duodenal loop. At 3 yr 2 mo of age she is in the 50th percentile for her weight for her age and is otherwise healthy.
Fig. I. Techniques for reducing diameter of dilated duodenum. (A) Resection of anterior wall. (B) Imbrication of anterior wall.
DUODENOMEGALY
463
Case 2 A 27-hr-old male infant was transferred when bile-stained emesis was noted and 200 cc of bilious material was aspirated from his stomach. Physical examination revealed a normal male newborn in no acute distress. He weighed 5 lb 12 oz and his vital signs were normal and stable. A b d o m i n a l x-rays revealed two large air fluid levels in the upper a b d o m e n . After stabilization, he was taken to the operating r o o m where exploration revealed a considerably dilated d u o d e n u m and proximal j e j u n u m secondary to a high-jejunal atresia and, distally, eight separate jejunal webs. Each web was removed t h r o u g h an enterotomy, and an end-to-end jejunojejunostomy was performed. Postoperatively he continued to drain large quantities of g a s t r o s t o m y drainage. A t t e m p t s at clamping the gastrostomy and feeding resulted in vomiting. A repeat x-ray series revealed an enlarged poorly functioning duodenal loop. After 4 wk o f total parenteral nutrition and failure to establish oral intake, he was returned to the operating room where the dilated duodenal segment was imbricated along its anterior border with interrupted 5-0 silk sutures from the pyloris to the ligament of Treitz to reduce the effective circumference by approximately 60~,, (Fig. IB). On the 15th postoperative day, feedings were started and progressed slowly until at 5 wk he was eating well and gaining weight. At 7 wk postoperative, he was discharged home. At 7 m o he was in the 10th percentile for weight for his age and tolerating all feedings well.
DISCUSSION
A greatly dilated segment of small bowel loses its ability to produce effective peristalsis as suggested by Louw ~ and Phelan s and proved by the experiments o f N i x o n . 7 In intestinal atresia and stenosis, resection of the proximal dilated segment is of the utmost importance for proper postoperative intestinal function. However, when the nonfunctional dilated segment is in the duodenum, as in high-jejunal and duodenal atresia or stenosis, resection is not technically feasible. It appears from our brief experience that longitudinal resection or imbrication of the dilated duodenal wall, thus reducing the effective diameter, may help to restore adequate peristaltic function and prevent the usual problems seen with duodenomegaly. Of the two procedures, longitudinal resection would seem to have the greatest potential for complications because of the long intestinal closure line and increased risk of leakage. If the invaginated duodenal wall resulting from imbrication does not interfere with peristalsis, it would seem to be the preferable procedure. Longitudinal resection and imbrication appeared to have worked equally well in the two cases presented. As far as we know, these are the only two patients in which this type of surgical approach has been applied to the problem. Further evaluation of these procedures is needed by us and others to determine their usefulness as an approach to the problem of nonfunctioning duodenomegaly. SUMMARY
Two cases of nonfunctioning postoperative duodenomegaly in infants are presented with a discussion of the complications associated with this problem. A new surgical approach of longitudinal resection or imbrication of the duodenal wall to reduce its effective diameter and thus restore peristaltic function is presented.
464
SHERMAN AND SCHULTEN
REFERENCES
I. Benson CD, Lloyd JR, Smith JD: Resection and primary anastomosis in the management of stenosis and atresia to the jejunum and ileum. Pediatrics 26:265, 1960 2. Evans CH: Atresias of the gastrointestinal tract, lnt Abstr Surg 92:1, 1951 3. Fonkalsrud EW, de Lorimer AA, Hays DM: Congenital atresia and stenosis of the duodenum. Pediatrics 43:79, 1969 4. deLorimer AA, Fonkalsrud EW, Hays DM: Congenital atresia and stenosis of the jejunum and ileum. Surgery 65:819, 1969 5. Louw JH: Resection and end-to-end anastomosis in the management of atresia and stenosis of the small bowel. Surgery 62:940, 1967 6. White JW: Effects of changing concepts
upon diagnosis and management of intestinal atresia. Am Surg 37:34, 1971 7. Nixon HH: An experimental study of propulsion in isolated small intestine and application to surgery in the newborn. Am Roy Coil Surg Engl 27:105, 1960 8. Phelan JT, Lemmer KE, McDonough KB: Jejunoileal atresia and stenosis. Surgery 46:430, 1959 9~ Brimblecombe FSW, More HD: Duodenal atresia and stenosis in infants. Ann Surg 172:991, 1970 10. Thomas CG: Jejunoplasty for the correction of jejunal atresia. Surg Gynecol Obstet 129:545, 1969 11. Louw JH: Congenital atresia and severe stenosis in the newborn. S Afr J Clin Sci 3:109, 1952