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Laparoscopic repair versus open laparotomy in congenital duodenal obstruction

JC Gouli¹, H Allal¹, F Paniagua², G Andrianandraina¹, N Kalfa¹, RB Galifer¹
¹Pediatric Visceral Surgery Department, Lapeyronie Hospital, CHU Montpellier, France
¹Pediatric Visceral Department, Hospital Niño Poblano, Puebla, México

 

Correspondence

Dr Jean-Christian GOULI
Pediatric Visceral Surgery Department.
Lapeyronie Hospital,
191 Avenue du Doyen Gaston Giraud,
34295 Montpellier, France
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: Congenital duodenal obstruction (CDO) is one of the most common anomalies in newborns. Laparoscopic approach nowadays is performed for CDO treatment. We present our result comparing laparoscopic repair (LR) versus open laparotomy (OL).

Patients and methods: We have done a retrospective analysis on records of all newborns admitted to our center from January 2000 to December 2008 with diagnosis of CDO, dividing them into 2 groups according to the operative approach. Operative time, hospitalization length, baby’s weight at entry and at discharge, time of initial and full oral feeding were analyzed statistically according to Student t test. The remaining data were listed as descriptive statistic.

Results: Twenty patients were enrolled. Age ranged from 1 to 17 days (three boys and 17 girls). Six babies (30%) were born prematurely (31 through 36 weeks gestation). Group 1 (LR) = 8 patients and group 2 (OL) =12 patients. The mean weight at surgery was: group 1= 2897.5g and group 2 2369.1g. Twelve patients (60%) had associated anomalies. The mean of the operative time was longer in group 1 (136.5 versus 99 minutes). The length of hospitalization was similar between two groups (15.3 vs. 16.8 days). Time of initial feeding (4.5 vs. 7.36 days) was statistically different. Two patients in group 2 presented obstruction due to intestinal adhesions after 2.5 and 4 years.

Conclusions: Length of hospital stay is similar in both approaches; feeding was earlier using LR. The cosmetic advantage and prevention of intestinal adhesions encourage the use of laparoscopy.

 

Keys words: congenital duodenal obstruction, laparoscopic repair, newborn

 

INTRODUCTION

Congenital duodenal obstruction (CDO) is one of the most common anomalies in newborns and infants. The causes of CDO are: intrinsic luminal occlusion (duodenal atresia, stenosis, and diaphragm) and obstructive complication of a malrotation or an annular pancreas. In 38-55% of patients, intrinsic duodenal obstruction is associated with another significant congenital anomaly [1]. Duodenal atresia is often associated with Down’s syndrome (30%), annular pancreas (23%), congenital heart disease (22%), malrotation (20%), oesophageal atresia (8%), others (20%) [2]. The mainstay of treatment is surgical intervention. Accepted therapy has consisted of laparotomy and duodenoduodenostomy with long-term results.

Advances in minimally invasive surgical techniques for the last 20 years have led to attempts at the laparoscopic repair of CDO [3]. A few of these repairs have been published with authors reporting success in single case reports and small case series [3-7]. Spidle et al. [3] had showed in their paper a largest series reporting the successful repair of CDOs using the laparoscopic approach. The aim of the current study is to determine in a short series our experience for the last eight years the efficacy and outcomes of laparoscopic repairs of CDO compared to laparotomy.

MATERIALS AND METHODS

A retrospective review of all patients with CDO between 2000 and 2008 in the Department of Visceral Surgery and Pediatric Urology, University Hospital of Montpellier, France, was conducted after obtaining approval from the department of patients charts (L651 HGCA003). Data extracted from the charts included sex, gestational age, age at operation, weight at operation, presence and type of vomiting, use of presence prenatal ultrasound for prenatal diagnosis and associated anomalies and the type of duodenal obstruction. Additionally, treatment data collected included operative approach, operative time and operative technique.

The laparoscopic operative technique repair was the following: the patient was placed supine at the end of the table, and the surgeon stood at the patient’s feet. A 5 mm 30° optical device was introduced into the abdominal cavity through an arciform incision using the “open laparoscopy” technique; the pneumoperitoneal pressure was 8 mmHg. Three 3 mm working trocars were inserted in the right and left flank and the epigastrium. Because of the decompressed nature of the distal bowel, there was abundant intraabdominal space and excellent visualization of the c-loop of the duodenum.

The epigastrium trocar accepted a palpator which retracts the liver. The duodenum was kocherized, and the site of the obstruction was easily visible in all cases. In the cases of atresia, proximal and distal duodenotomy were made, and a standard diamond anastomosis was performed using 4-0 silk sutures. Stay suture were placed at each corner to set up the anastomosis, and then the back wall and then front wall were sewn. The distal bowel then was run to look for evidence of other, distal atretic segments. In the cases a web was suspected, a longitudinal duodenotomy was made across the area of apparent transition. A web was identified, partially resected, and a transverse closure was performed with running suture. Outcome data included length of hospitalization after operative repair, whether a nasogastric tube we used, duration of parenteral feeding, time to full oral enteral feeding, length of follow-up, and all post operative complications and/or interventions. Finally, babies weight at the end of hospitalization and all radiologic examinations were reviewed. Statistical evaluation performed between babies with laparoscopic approach, with traditional open approach, consisted of unpaired student t test for operative times, length of hospitalization, babies weight at way-out and time to initial and full oral feedings. Descriptive statistics are listed as mean.

RESULTS

Twenty pediatric patients with duodenal congenital obstruction were treated over an eight years period. Three were boys and 17 were girls. Seventy patients (85%) presented during the first week of the life and 3 during the first month. Mean gestational age for all patients was 37,1 weeks with extreme 31 weeks and 41 weeks. Of the 17 patients who presented in the neonatal period, 5 (30%) were premature, and 13 (75%) had low or very low birth weight. Mean birth weight for the entire cohort was 2580,5g with extreme 1000g and 3400g. Congenital anomalies were shown in table 1.

Forty patients (70%) had duodenal obstruction diagnosed on prenatal ultrasound scan. The remainder all presented with vomiting. The vomitus or gastric aspirate was bilious in 4 patients (20%). Plain abdominal films were performed in 16 patients and showed the typical double bubble with or without distal gas in 11 (75%) of them. 15 patients received an ultrasonography at birth, showing a duodenal obstruction. For the repair of CDO, two modalities were used. 12 underwent a traditional open approach, and 8 patients underwent a laparoscopic operation. Outcomes variables are listed in table 2.

Table 1: Congenital anomalies in babies undergoing repair of congenital duodenal obstruction

Associated congenital anomaly

Work force

Percentage

Total

12

60%

Trisomy 21

3

15%

Congenital heart disease

4

20%

Esophageal atresia

2

10%

Vertebral anomaly

1

5%

Other intestinal anomaly

2

10%

Table 2: Mean outcome variables in the babies undergoing repair of congenital duodenal obstruction

Outcome variables

Laparotomy (n=12)

Laparoscopic approach (n=8)

Age

4,75 days

3 days

Babies weight

2912g

3175 g

Operative time

99 min

136 min

Length of parental feeding

7 days

4 days

Nasogastric (NG) tube removal

5 days

4 days

Time to full oral feeding

14 days

8 days

Length of postoperative hospitalization

17 days

15 days

Complications

3n

0



Operative time was significantly different between two groups with T student test < 0,05. The length of post operative hospitalization, parietal feeding, and time to full oral intake were all statistically shorter in patients undergoing a laparoscopic repair. Babies’ weigth at the end of hospitalization was higher after laparoscopic duodenal obstruction repair. We found in the group of OL two intestinal occlusion on intestinal band and one death after open surgical repair of congenital duodenal obstruction due to associated anomalies. No complication after laparoscopic repair in our study. Eight patients underwent duodeno-duodenal anastomosis. In the open surgical group we have done duodeno-duodenal anastomosis, duodeno-jejunostomy and duodenal diaphragm resection. All patients had a nasogastric tube in place at the time of operation that was removed at the time of initiating feeding. There were no duodenal leaks in the 20 patients.

DISCUSSION

Our report is short and represents the half of Spidle et al. [3] series who had described the largest laparoscopic approach for repair of CDO. They used U-clip and founded that it’s especially advantageous in its application for the repair of CDO as it was developed for small anastomoses (vascular anastomosis). A unique finding of our study is that CDOs can be repaired safely via the laparoscopic approach using silk suture. The ability to perform delicate dissection and intracorporeal anastomosis has broadened the scope entities that can be approached. We agree with Rothenberg [4] that, although most neonatal conditions presenting with bowel obstruction present a difficult problem for laparoscopy because of the dilated bowel and limited abdominal cavity, this is not the case in duodenal atresia.

The entire small and large bowel is decompressed, and there is excellent exposure of the proximal duodenum. We have previously described our operative technique for laparoscopic repair of CDO using silk suture. Two unexpected benefits of this technique are the excellent visualization of the site of the obstruction and the ease of the anastomosis. We feel that one of the difficulties of performing the duodeno-duodenostomy through a standard right upper quadrant laparotomy is constructing the anastomosis between the bulbous proximal segment and the relatively small-caliber distal duodenum. Exposure can often be difficult. With a laparoscopic approach, the scope can be placed directly over the anastomosis, providing excellent visualization. The back wall is seen easily, and because no retractors are necessary, the front wall is nearly approximated to the anterior surface of the distal bowel. The standard diamond type anastomosis thus, is constructed easily without tension [8]. Regarding patients outcomes, we found that the laparoscopic approach for CDO repair result in significantly shorter length of postoperative hospitalization, shorter length of parenteral feeding and shorter time to full oral feeding.

As has been suggested by multiple authors comparing laparoscopic and laparotomy approach, these reductions may be attributed to less inhibition of bowel function and an abbreviated ileus related to the laparoscopic approach when compared to the open operation [3, 4, 6, 7]. Our series was shorter than Spidle et al [3] series (15 patients), but largest than Rothenberg et al. [4] series (5 patients), Nakajima et al. series [7] (2 patients) and Bax et al. [6] case report. Spidle et al. [3] also suggested an alternative mechanism for these findings. Traditionally, they have used the volume and character of the fluid returned from the nasogatric (NG) tube as an adjunct indication for return of bowel function in patients with CDOs. It was old practice to remove the NG tube when the daily volumes decreased and were no longer bilious in nature. Often this took weeks to occur.

With the development of the laparoscopic approach and the routine use of postoperative upper gastrointestinal (UGI) contrast studies to evaluate for anastomotic leaks, the NG tubes were removed after the contrast study showed no leak and contrast passed through the anastomosis [3, 9]. In our study the mean time to NG tube removal for the laparoscopic group was 5 days like Spidle et al. [3] series with initial feeding began few hours later. In both studies, the laparoscopic repair and open approach had a low incidence of postoperative stricture formation (one in their series and none in ours). According to us one possible disadvantage of laparoscopic CDO repair may be that evaluation of distal bowel for atretic segments is more difficult to accomplish.

The bowel can be inspected visually for distal obstructed segment, but internal webs may be more difficult to see, that was possible in open approach. We believed that this difficulty has been reducing by prenatal diagnosis and efficient preoperative ultrasound (US) at birth which had been done in 75% of cases in our series. Bowel malformation is becoming less and less of neonatal surprise. US investigation and fetal resonance imaging now provide an accurate malformative assessment, improving significantly the etiological orientation [9]. Although not statistically significant, the operative time during our study favored the open approach by 37,5 minutes (99 vs 136,5 minutes).

Although babies mean weight at the end of hospitalization was greater in laparoscopic repair than laparotomy (3175 vs 2912 grammes). However, with experimented surgeon laparoscopic repair operative time and its cosmetic superiority can be benefic for patients. At mean follow up (425 days) in our study, laparotomy provided postoperative complication as bowel obstruction by intestinal band in 2 patients (16%) and none complication in laparoscopic CDO repair. In their paper Escobar et al. [10] showed late complications occurring in 12% of patients with congenital duodenal anomalies after long-term follow-up (over 30 years); they also recommended follow-up into adulthood for these patients.

CONCLUSION

Up to this time, laparoscopic repair of CDO proved few advantages to traditional surgical approach. This is a short series reporting the successful repair of CDO using the laparoscopic approach. It is showed that the use of silk suture to perform the anastomosis was a simple, reproducible, and reliable technique that can be used by laparoscopic surgeons with a wide range of technical abilities. The benefits of laparoscopic approach appear to include a short hospital stay and faster return to feeds, as well as the superior cosmetic results and avoidance of a painful muscle splitting incision.

 

 

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