Currently, a diamond-shaped anastomosis is preferred for the surgical repair of duodenal atresia (DA) in both open and laparoscopic surgery. We report the results of laparoscopic duodenoduodenostomy with parallel anastomosis (LDPA) in DA.
We retrospectively reviewed 22 patients who underwent laparoscopic duodenoduodenostomy from February 2005 to May 2015 in Samsung Medical Center. All patients underwent operation within the first month after birth. Patients who were transversely anastomosed after duodenotomy and patients who underwent simultaneous operation on combined anomalies were excluded. Parallel anastomosis was used in all surgeries. Four trocars were used in laparoscopic repair. After mobilization of both proximal and distal ends, the proximal end was incised transversely and the distal end was incised longitudinally. Duodenoduodenostomy with parallel anastomosis using a 5-0 glyconate monofilament was performed with interrupted sutures.
Eleven patients (50 %) were male. Median gestational age was 36 + 6 weeks (32 + 7–40 + 6). Median age at the time of operation and median body weight were 3 days (1–12) and 2.53 kg (1.63–3.18), respectively. All patients were diagnosed prenatally and 16 patients (72.7 %) had associated anomalies. Median operation time was 142 min (96–290) and median postoperative day to start oral feeding was 5 days (3–9) and median postoperative day of reaching full feeding was 11 days (6–19). Median postoperative day was 13 days (10–60). There was no anastomotic leakage or stenosis. Median follow up was 3.5 months (1–21). Currently, there is no late complication.
LDPA can be performed easily to patients who have DA in neonatal period. It is anatomically natural and the risk of leakage or stenosis does not seem significant. Therefore, parallel anastomosis should be considered as a safe procedural option for laparoscopic duodenoduodenostomy in DA.
Duodenal atresia is the main cause of congenital duodenal obstruction and occurs once in every 10,000 live births [1, 2]. More than 50 % of DA patients have combined anomalies [2–4]. In 1932, Ladd et al.  reported the first surgical correction of DA. Until the 1970s the standard procedure for anastomosis of DA was duodenoduodenostomy or duodenojejunostomy with a parallel anastomosis [6–10]. In 1969, Fonkalsrud et al.  reported that the mortality rate of DA and stenosis was 32 %, and that half of these mortalities were related to anastomotic complications. In 1977, Kimura et al. [11, 12] introduced a new approach using a diamond-shaped anastomosis that has since been utilized by many centers. Even after the introduction of laparoscopic repair of DA by Bax et al.  in 2001, the diamond-shaped anastomosis is still considered the gold-standard procedure [14–17]. However, there is insufficient literature on laparoscopic duodenoduodenostomy with parallel anastomosis (LDPA). In our center, we routinely perform LDPA and have found this procedure to be easy to perform and also more anatomically natural compared to the diamond-shaped anastomosis. Herein we report the results of LDPA with low rates of postoperative anastomosis leakage or stenosis.
Materials and methods
We retrospectively reviewed 22 patients who underwent laparoscopic duodenoduodenostomy from February 2005 to May 2015 in Samsung Medical Center. All patients were confirmed to have DA in the operating field. Patients with DA who underwent duodenoduodenostomy in their first month of life were included. Patients who underwent transverse anastomosis after longitudinal duodenotomy and patients who underwent operations for combined anomalies simultaneously with duodenoduodenostomy were excluded. The study included 22 patients who underwent laparoscopic repair involving duodenoduodenostomy with parallel anastomosis. Patient data including sex, gestation age, prenatal diagnosis, associated anomalies, body weight and age on the day of surgery, operating time, postoperative hospital course and perioperative complications were collected.
The laparoscopic technique was as follows. Patients were positioned at the end of the operating table. The operator stood on the caudal side of the patient while the scopist stood on the left side of the operator and the scrub nurse stood on the right side of the operator. The monitor was placed in front of the operator. Four trocars were inserted: a transumbilical camera port (5 mm), two working ports (3 mm) on either side of the umbilicus, and one assistant’s port (3 mm) on the epigastric area (Fig. 1).
After dissecting the distal portion of the stomach, the proximal end of the dilated duodenum can be identified. The distal duodenal end of the atretic portion can be identified with a retroperitoneal approach. After dissection, most cases showed a natural alignment as illustrated in Fig. 2A. It is important to make both sides redundant to minimize possible tension on the anastomosis before opening the duodenum. At this time, a lumbar puncture needle (22 gauge) is percutaneously inserted into the distal bowel to inject saline into the distal bowel and confirm distal passage. A seromuscular tagging suture was made on both tips of the planned anastomosis site to fixate the bowel during the procedure. The bulbous proximal duodenum was opened with an endoscissor transversely on the distal part of the anterior wall. The distal duodenum was opened longitudinally. The incisions are parallel because of the perpendicular alignment of proximal and distal duodenum. The incisions are made as long as possible to avoid stenosis. Interrupted sutures using 5-0 glyconate monofilament (Monosyn, B Braun, Melsungen, Germany) were performed on the posterior wall. The first suture on the upper edge of the posterior wall is retracted upper and ventrally by the assistant to facilitate further procedures. The anterior wall is subsequently anastomosed with interrupted sutures. A transanastomotic tube is not routinely inserted (Fig. 2).
We routinely try to identify the duodenal papilla but this is not possible in all cases. When the papilla is seen through the longitudinal incision on the distal bowel segment, much care is taken not to injure the papilla during anastomosis. In cases where the papilla is not readily identified, no further attempts are made to locate the structure.
The patient is monitored postoperatively in the neonatal intensive care unit. Feeds are initiated when passage of gas into the small intestines are observed on abdominal radiograph and drainage from the nasogastric tube is less than 5 cc/kg/day. 10 cc per feed of breast milk or formula is given at first and then built up by 10 to 20 cc/day until the patient reaches full feeds.
This study was approved by the Institutional Review Board at Samsung Medical Center (IRB File No. 2015-07-006-003).
There were 11 (50.0 %) male patients. Median gestational age was 36 + 6 weeks, median birth weight was 2.72 kg, median age at the time of operation was 3 days and median body weight at the time of operation was 2.53 kg. The proportion of patients with combined anomalies was 72.7 %. Combined anomalies were 6 patients with Down’s syndrome, 11 cardiac anomalies, 1 brain anomaly, 1 imperforate anus, 1 Hirschsprung’s disease, 1 laryngomalacia, 1 tracheomalacia, and 3 limb anomalies (Table 1).
None of the cases were converted to open repair. Median operation time was 142 min. Median time of first stool passage was postoperative 3 days and first oral feeding was postoperative 5 days. Median time to reach full oral feeding was 11 days. Median postoperative hospital stay was 13 days and median follow-up period was 3.5 months.
All patients were diagnosed prenatally. One patient who was discharged 60 days after LDPA underwent operation for cardiac anomaly on the 28th postoperative day and operation for Hirschsprung’s disease on the 52nd postoperative day. One case of postoperative complication occurred: tension pneumothorax that resolved after conservative management. There was no anastomotic leakage or stenosis. No late complications were seen during the postoperative follow-up period.
DA is one of the main causes of emergent surgery in the neonatal period. A delay in diagnosis and operation can lead to aspiration pneumonia and malnutrition. Currently, most cases are diagnosed prenatally with ultrasonography, although DA can also be confirmed with the typical double-bubble sign with gasless abdomen in a plain radiograph taken after birth .
The mortality rate was 40 % when Ladd et al. first reported their surgical repair of DA; however, it has dropped to 5–10 % with improvements in neonatal intensive care, parenteral nutrition, operative techniques and management for combined anomalies. Currently, mortalities seen in DA are mostly due to combined anomalies .
Laparoscopic surgery is considered to be superior to open laparotomy in visualization, bowel assessment, cosmesis and postoperative adhesions . The boundaries of pediatric laparoscopy have been widened markedly over the last 2 decades. Although many surgeons investigated the practicability of laparoscopic repair of DA after the first report in 2001, the results were disappointing with abundant postoperative leakage . In 2007, anastomosis using a U-clip was first reported as a solution . However, with improvements in laparoscopic techniques including intracorporeal suturing, many surgeons began reporting similar leakage rates and superior recovery compared to open laparotomy [15–17, 21–23].
Before the 1970s, anastomosis of DA was usually performed side-to-side. However, blind loop syndrome and anastomotic stenosis or leakage frequently occurred and were considered to be related to the bowel function on the anastomotic site . In 1977, Kimura et al.  reported their diamond-shaped anastomosis with a larger stoma and claimed that the recovery of bowel function was faster with their method of anastomosis. In their report published in 1986, Weber et al.  compared various types of duodenoduodenostomies and concluded that a diamond-shaped anastomosis was related to earlier feeding and discharge. However, a diamond-shaped anastomosis requires more dissection of the distal duodenal stump and usually results in abnormal morphology .
In our study, we wanted to point out the usual perpendicular alignment of the proximal and distal bowels (Fig. 2A). With a transverse incision on the proximal end and a longitudinal incision on the distal end, duodenoduodenostomy with parallel anastomosis is possible. An advantage of the parallel anastomosis is that it is possible to anastomose the proximal and distal segments with minimal dissection and mobilization because the two atretic segments are usually aligned in a perpendicular configuration. Moreover, the duodenum can remain positioned in the retroperitoneum with a natural C-loop shape after completion of the anastomosis. We consider this more anatomically natural than a diamond-shaped anastomosis, which requires the lower end of the distal longitudinal incision to reach the midpoint of the proximal incision. Minimal dissection around the duodenum and surrounding structures should be practiced whenever possible during surgical procedure on a neonate.
Functional outcomes of our LDPA were comparable to previous published reports of laparoscopic DA repair using various anastomosis techniques. As in other published studies, we started feeding with consideration of the amount of drainage from the nasogastric tube and the gas pattern in plain radiography. Among five published studies of laparoscopic repair for congenital duodenal obstruction that were published after 2008, four [15, 16, 22, 25] performed diamond-shaped anastomosis and one study  did not describe the type of anastomosis. These studies showed similar results to our study regarding first oral feeding and time taken to reach full oral feeding (Table 2). Also, we have not encountered postoperative anastomotic stenosis after LDPA. Previous studies have reported 0–6 % rate of stenosis or stricture at the anastomosis site, as shown in Table 2.
Leakage and stenosis are the greatest concerns in bowel anastomosis. Although it has been reported that interrupted suture is associated with less stenosis and more leakage compared to continuous suture, there is insufficient supporting evidence [26, 27]. One study reported no leakage in laparoscopic duodenoduodenostomy after changing from interrupted suture to continuous suture . In our study, there was no leakage despite the use of interrupted sutures. Although the use of interrupted sutures is more time-consuming, with an improvement in operating skills (such as intracorporeal suture technique and identification of full-layer suture) the operating time can be reduced. The last procedure mentioned in our study was completed in 96 min. The authors have performed 13 cases of open duodenoduodenostomy for congenital DA. The operation time of open duodenoduodenostomy ranged from 47 to 125 min, with a median operation time of 74 min.
A limitation of this study is that we did not compare LDPA with laparoscopic duodenoduodenostomy with diamond-shaped anastomosis. A prospective randomized trial will be necessary to further assess the benefit of this procedure.
LDPA can be safely performed in neonates with congenital DA. It is anatomically natural and the risk of leakage or stenosis appear comparable to laparoscopic duodenoduodenostomy with diamond-shaped anastomosis. Therefore, parallel anastomosis may be considered as a procedural option for laparoscopic duodenoduodenostomy in DA.
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Dr. Chaeyoun Oh, Dr. Sanghoon Lee, Dr. Suk-Koo Lee and Dr. Jeong-Meen Seo have no conflicts of interest or financial ties to disclose.
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Oh, C., Lee, S., Lee, SK. et al. Laparoscopic duodenoduodenostomy with parallel anastomosis for duodenal atresia. Surg Endosc 31, 2406–2410 (2017). https://doi.org/10.1007/s00464-016-5241-y
- Laparoscopic duodenoduodenostomy
- Parallel anastomosis
- Duodenal atresia
- Diamond-shaped anastomosis