Laparoscopic duodenoduodenostomy in neonates: Report of two cases and review of the literature.

Congenital duodenal obstruction is traditionally managed by laparotomy. Laparoscopic duodenoduodenostomy (LDD) in neonates is considered a technically demanding operation requiring advanced pediatric laparoscopic skills. To the best of our knowledge, there are no reports of LDD from the Indian subcontinent. Here, we report two cases of successful LDD in neonates and review the relevant literature.

INTRODUCTION

Duodenal atresia and stenosis are intrinsic duodenal obstructions occurring in 1 in 6000 live births and are often associated with other anomalies, including trisomy 21 and cardiac malformations.[1]

The management of the patient with duodenal atresia has steadily evolved since the first report of surgical correction of intrinsic duodenal obstruction by Ladd in 1931.[2] At that time, reported mortality was 40%. Over the last few decades, advancements in neonatal intensive care, parenteral nutrition, and management of associated anomalies, and improvements in operative technique and postoperative care have improved the outlook for patients born with this condition. Mortality has been reduced to 5-10% and is now related mostly to associate anomalies, primarily cardiac.[13]

Various techniques have been described for the repair of duodenal atresia, but the diamond-shaped duodenoduodenostomy described by Kimura in 1990[4] has become the standard. The introduction of advanced laparoscopic techniques in the neonate has more recently led to a new surgical approach, the laparoscopic duodenoduodenostomy (LDD).[56789]

Laparoscopic duodenoduodenostomy is considered a technically demanding operation, with a high conversion rate to open surgery. We report our experience with two LDDs in neonates. To our knowledge, this is the first report neonatal LDD from the subcontinent.

CASE REPORTS

Case 1

A 2-week-old, 2 kg baby boy with trisomy 21 was referred with complaints of bilious vomiting since birth. Contrast swallow done prior to referral had shown a grossly dilated proximal duodenum with a little contrast entering the distal bowel suggestive of a type I duodenal atresia [Figure 1]. After initial stabilization, the baby was taken up for laparoscopic repair. Three ports were used, a 5 mm umbilical telescopic port and two 3 mm ports in the left upper and right lower quadrants [Figure 2]. Pneumoperitoneum was maintained between 6 and 8 mm Hg. The proximal dilated the duodenum was hitched to the abdominal wall with two stay sutures, and the distal collapsed duodenum was exposed by reflecting the hepatic flexure of the colon. The dilated duodenum was opened transversely just proximal to the atresia. The distal duodenum was opened vertically. Duodenoduodenostomy (diamond) was performed using single layer of interrupted 5/0 vicryl sutures with intracorporeal knot tying, the posterior wall being sutured first. A glove drain was placed through the right lower quadrant port site. The operation took about 90 min, and the child recovered well. He received parenteral nutrition and nasogastric tube drainage for 1-week, by which time the bile aspirates had stopped. He underwent a dye study, which showed free flow across the anastomosis. He was started on oral feeds which he tolerated well and was discharged home 5 days later. At 1-year follow-up, he is feeding well and thriving well. The cosmetic result has been excellent.

Figure 1

Preoperative upper gastrointestinal study in patient 1 demonstrating duodenal obstruction

Figure 2

Schematic diagram showing port sites

Case 2

A 2.6 kg, full-term newborn baby arrived in the NICU with an antenatal diagnosis of duodenal obstruction, after a cesarean delivery. There were no polyhydramnios and no evidence of any other congenital anomalies. He had bilious aspirates in the nasogastric tube. After initial stabilization, the diagnosis of duodenal obstruction was confirmed by a plain radiograph taken after injecting 30 ml of air into the stomach; the classic “double bubble" sign (dilated stomach and duodenum) was seen with no air distally. On day 2 of life, he underwent laparoscopic repair of duodenal obstruction. At laparoscopy, apart from annular pancreas, he also had malrotation of the bowel. This was corrected by Ladd's procedure, after which a duodenoduodenostomy was performed, as described previously. The entire operation was completed laparoscopically in about 130 min. Postoperatively, the baby recovered well, and oral feeds were started 7 days after surgery. The child was discharged 2 weeks after surgery and is thriving well at a follow-up of 6 months.

DISCUSSION

The initial reports of LDD came in 2001-2002.[56] Since then, laparoscopic repair of congenital duodenal obstruction has become popular. Several case series of LDD have demonstrated that the procedure is safe and efficacious. Kay et al.[7] reported a series of 17 LDD procedures with no short-term complications and excellent results. Apart from the excellent cosmetic benefit of laparoscopy, Spilde et al.[8] compared laparoscopic and open procedures and demonstrated that time to initiation of feeding was shorter in cases completed laparoscopically (5-8 days for laparoscopic vs. 8-11 days for open groups), as has time to discharge (12-21 days for laparoscopic vs. 20-24 days for open groups).

Laparoscopic duodenoduodenostomy has historically been regarded as technically challenging, especially in neonates, due to the small space available for suturing. Burgmeier and Schier[9] reported that more than a quarter of their cases were converted to open. In a recent multicenter experience,[10] there was a 35% conversion rate from laparoscopic to open the procedure. However, the authors concluded that laparoscopic technique could be safely applied across multiple centers with similar outcomes to traditional open repair and the cosmetic benefits associated with laparoscopy.

In terms of the technical difficulty of LDD in neonates, the Netherlands experience[11] may be particularly noteworthy. After their early enthusiasm,[1] the authors realized that they had unacceptably high leak rates after LDD.[11] Hence, they abandoned the laparoscopic procedure for many years. They restarted laparoscopic operation after they gained adequate experience in advanced laparoscopy and suturing. They also made some technical modifications to the procedure, whereby they reported excellent success with few complications. The authors concluded that laparoscopic repair of duodenal atresia should, therefore, be restricted to pediatric centers with extensive experience in laparoscopic surgery and intracorporeal suturing.[11] To overcome the technical difficulty of LDD, novel techniques like U clips[12] and robotic surgery[13] have been tried. Robotic surgery in neonates has not become popular due to cost concerns and the current use of adult instruments.

In our experience with two cases of neonatal LDD, we found that the operation could be safely and successfully be done by conventional laparoscopy. One of our cases was complicated with the additional presence of malrotation, but we could safely combine laparoscopic Ladd's procedure with LDD in this neonate and the baby had an excellent result. The association of duodenal atresia with malrotation is well documented in the literature.[7] In type 1 atresias (duodenal web), either duodenotomy with excision of the web or duodenoduodenostomy may be done. Like other authors,[7] we prefer to do a duodenoduodenostomy (as in our case 1) because of the theoretical risk of injuring the ampulla during web excision.

There is a concern that while doing laparoscopy for duodenal atresia, other distal atresias may be missed. However, in a large series of 408 patients operated for duodenal atresia,[14] the incidence of concomitant distal atresia was found to be <1%.