What is Intestinal Atresia?

It is the incomplete development of the continuity of the intestines during the development of the baby in the womb. Duodenal (duodenal) atresia, jejuno-ileal atresia and colonic atresia are evaluated under this heading. In this article, the causes of duodenal obstruction will be evaluated.

What is Duodenal Obstruction in Newborns and Babies?

It is the lack of continuity of the Duodenum (the first section of the Small Intestines after the stomach) during the development of the baby in the womb.

What are the Main Causes of Duodenal Obstruction in Newborns and Babies?

The main causes are duodenal atresia, duodenal stenosis, annular pancreas, malrotation, preduodenal portal vein and duodenal duplication.

What are the Theories of Formation of Duodenal Atresia?

There are a number of theories explaining the formation of duodenal atresia, but the exact cause is unknown. The theory that is still accepted today is the recanalization theory. According to this theory, all intestines are lumenless during development in the womb, but later become hollow lumens. Any problem at this stage causes duodenal atresia.

Who is Duodenal Atresia More Common and How Frequently?

Duodenal atresia is seen in one in every 5000-10000 live births. It is more common in male babies than in female babies.

Are There Types of Duodenal Atresia?

Yes, there are. Although different classifications have been made, the most commonly used classification is as follows.

Type 1; There is a diaphragm or membrane in the diaphragmatic lumen, when viewed from the outside, the intestinal integrity is not impaired. This structure is called a Web and is also called the Windsock anomaly in appearance.

Windsock anomaly is a type of Type 1 atresia. In this anomaly, the web that obstructs the intestinal lumen prolapses more distal to the intestinal lumen. When viewed from the outside, the intestine that obstructs the intestinal lumen prolapses more distal to where it is attached to its wall, so atresia appears to be more distal to the intestine. However, when looked at carefully, the area where the web attaches to the intestinal wall can be noticed in some cases.

Type 2; atresic blind ends are connected to each other with a fibrous band, there is no defect in the intestinal meso. Luminal integrity is also impaired.

Type 3; Atresic ends are separate from each other, intestinal mesoderm defect is present.

 

What are the Additional Anomalies That Can Be Seen in Duodenal Atresia?

Additional anomalies are seen in 50% of duodenal atresia cases. In other words, it is a disease where accompanying anomalies are frequently seen. The most common anomalies are; Down syndrome 30%, congenital heart diseases, esophageal atresia, genitourinary system anomalies, malrotation, annular pancreas, other intestinal atresias, bile duct anomalies

Can Duodenal Atresia Be Diagnosed Antenatally (In the Womb)?

A definitive diagnosis cannot be made, but there may be ultrasound findings that raise the suspicion of duodenal atresia, which are; maternal polyhydramnios is seen in 30-65% of patients, and the first section of the stomach and duodenum is observed as fluid bubbles

How is Duodenal Atresia Definitively Diagnosed?

A definitive diagnosis is made after the baby is born with the history and physical examination. This diagnosis is confirmed with imaging methods. In the history, ultrasound findings performed in the womb should be questioned, the baby starts vomiting bile within a few hours after birth, so the form and time of vomiting should be questioned carefully. Premature birth is common in these babies. In the physical examination, the abdomen is sunken, gas and food are not passing down, and the stomach is distended and peristaltic. In the physical examination, care should be taken to investigate additional anomalies.

Normally, the amount of stomach content aspirate in the newborn is around 5 mm, and in these patients, aspiration of more than 20 cc of stomach content when a nasogastric tube is placed is a warning for intestinal atresia.

Imaging methods; In the Standing Plain Abdominal X-ray (ADBG); double bubble (double gas) image (dilated stomach and gas-filled chambers belonging to the duodenum), no air in the distal small intestines,

 

However, sometimes distal (below) gas may be present, in which case incompletely obstructed atresia or other diseases in the differential diagnosis should be considered. For this, barium stomach duodenum radiography can be performed, and sometimes endoscopy may be necessary in older children.

 

If the patient has vomited, the double bubble image can be revealed by giving 40-60 ml of air through the nasogastric tube.

Echocardiography may be useful, especially for additional cardiac anomalies, and ultrasonography for genitourinary system anomalies.

How is Duodenal Atresia Treated?

The definitive treatment for duodenal atresia is surgical correction. However, there are certain treatment steps that must be taken into consideration and performed before surgery to reduce the risk of mortality and morbidity. These are; preventing the baby from vomiting and the stomach contents from entering the lungs (aspiration), for which the patient is not fed and a nasogastric tube is inserted. Serum treatment is started to replace the patient's fluid and electrolyte losses. Antibiotics are started, necessary precautions are taken to prevent the baby from going into hypothermia, and a urinary catheter is inserted if there is excessive fluid loss.

Operative approach to duodenal atresia:

The definitive treatment for duodenal atresia is surgery, as mentioned above. The method may vary depending on the type of atresia.

 

How is Duodenal Atresia Follow-up Done After Surgery?

The treatment process can take 5-10 days, sometimes longer. Fluid electrolyte support is continued, sometimes total parenteral nutrition may be required, and patients can be started to be fed orally after the color of the content coming from the nasogastric tube has lightened and its amount has decreased. It can sometimes take up to 3 weeks for oral feeding to start. The patient who is fed completely orally is discharged if there are no additional complaints.

If there are clinical complaints, in this case, medicated radiographs can be taken considering the presence of additional anomalies or that the surgery has failed.

What are the Risks and Complications of Duodenal Atresia Surgery?

Since the patient will receive anesthesia, there may be risks and complications (such as respiratory distress, heart problems), and in surgery, some problems such as anastomosis leakage, stenosis, bleeding, intra-abdominal infection, wound infection can be encountered. In addition, anastomosis stenosis can also be seen in the late period.

Prognosis in duodenal atresia also depends on the accompanying anomalies. Today, survival rates are around 95% in the absence of additional anomalies.

Can Duodenal Atresia Be Performed with Laparoscopic (Closed) Method, Are There Any Advantages?

Yes, it can be done.

However, it should not be forgotten that Laparoscopy (Closed) surgeries require serious experience, knowledge and skill along with advanced technology. Otherwise, it should not be forgotten that serious complications may occur.

Does Laparoscopic (Closed) Surgery Have Advantages Over Open Surgery?

Yes, there are, the main advantages are listed below;

• Less pain
• Less bleeding
• Less infection
• Less surgical scars or even no scars
• Shorter hospital stay
• Faster and easier recovery

How is Laparoscopic (Closed) Surgery Performed?

Carbon dioxide (CO2) gas is injected into the abdomen through the tiny holes opened in the abdomen to create a large area in the abdomen and the abdomen is inflated. Three 0.3-1 cm wide incisions are made in the appropriate places on the skin, one of which is from the belly button, and new tubes are placed. The planned surgery is performed by placing “long surgical instruments” through these newly added tubes.

However, it should not be forgotten that Laparoscopy can cause more serious complications when performed by inactive people.

What is Done Before Duodenal Atresia Surgery?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process, that is, before the surgery, during the surgery and after. If the child is older, the child is also included in this. A number of tests are performed, these tests are not general and are determined according to the patient. The patient is also seen by the anesthesiologist, the family and the child are informed about the anesthesia process that will be experienced. The patient is fasted for 4 hours before the surgery.

 

Does Duodenal Atresia Recur After Surgery?

It does not recur, but occasionally anastomotic stenosis may occur.

What is Annular Pancreas?

Annular pancreas is a rare congenital anomaly characterized by the complete or incomplete surrounding of the second part of the duodenum with a ring-shaped pancreatic tissue.

Although it has also been reported in adults, symptomatic cases usually present in infancy or early childhood. It can affect everyone from the newborn period to adulthood, and its diagnosis is difficult because it can present itself in many clinical manifestations such as pancreatic tumors, pancreatitis, obstructive jaundice, duodenal obstruction and peptic ulcer disease.

 

Why Does Annular Pancreas Form?

The exact cause of formation is not known, but some theories have been put forward. The most accepted theory is the theory put forward by Leeco. According to this theory, the anterior bud of the pancreas abnormally adheres to the duodenum, and this abnormal adhesion leads to an inappropriate rotation of the anterior bud around the second part of the duodenum during the seventh week of embryonic life. It is then suggested that the second part of the duodenum is partially or completely surrounded by a ring-shaped pancreatic tissue that also includes the main pancreatic duct, resulting in the formation of the annular pancreas.

How is Annular Pancrasis Diagnosed and Treated?

Diagnosis and treatment are similar to Duodenal Athesia. However, Computed Tomography and Magnetic Resonance Imaging methods, which we do not use in the diagnosis of Duodenal Atresia, are very helpful methods in terms of showing the pancreatic tissue.

What is Duodenal or Antral Web?

Congenital webs of the small intestine are a subtype of intestinal atresia. Although they can develop anywhere in the gastrointestinal system, they are most commonly seen in the antral region of the stomach and the 2nd region of the duodenum of the small intestine. Depending on whether the web is intact or fenestrated, clinical complete or partial obstruction occurs. Unlike duodenal atresia, which can be detected early from the antenatal period, fenestrated web cases can be diagnosed late in infancy and childhood, except for the neonatal period, depending on the size of the opening in the web.

What are the Clinical Complaints of Webs?

The most common and basic clinical complaint is vomiting. Vomiting can be bilious (light yellow) or clear (non-bilious) depending on the localization of the web. If the web opens below the 2nd part of the duodenum, where the bile ducts open into the gastrointestinal system, it is bilious, and if it is above it, it is clear. The timing of vomiting may vary depending on the width of the opening in the web. Vomiting may begin after birth, when the baby starts solid food, or later. There may also be swelling in the upper abdomen.

How to Diagnose Webs?

The most important thing in diagnosis is the history and physical examination. Also, imaging methods and Endoscopy are used.

• Standing Abdominal X-ray
• Contrast-enhanced stomach duodenum X-ray
• Endoscopy

 

 

How is Web Treatment Performed?

Web treatment is surgical. Surgery can be performed open and laparoscopic (closed).

Can Web Treatment Be Performed Laparoscopically, Are There Any Advantages?

Web surgery can be performed laparoscopically at any age. However, when performed by inexperienced people, the duration of surgery may be longer and mortality and morbidity may be higher.

After laparoscopic surgery, the patient is fed for 2-3 days and discharged from the hospital for 5-6 days. There is a long-term success rate of over 90% after surgeries performed by experienced surgeons on the subject.

Does Laparoscopic (Closed) Surgery Have Advantages Over Open Surgery?

Yes, there are, the main advantages are listed below;

• Less pain
• Less bleeding
• Less infection
• Less surgical scars or even no scars
• Shorter hospital stay
• Faster and easier recovery

How is Laparoscopic (Closed) Web Surgery Performed?

The abdomen is inflated by injecting carbon dioxide (CO2) gas into the abdomen through tiny holes opened in the abdomen to create a large area in the abdomen. New tubes are placed by making 3 0.3-1 cm wide incisions in the appropriate places on the skin, one of which is in the belly button. The planned surgery is performed by placing “long surgical instruments” through these newly added tubes.

However, it should not be forgotten that Laparoscopy can cause more serious complications when performed by inactive people.

What is Done Before Web Surgery?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process, that is, before the surgery, during the surgery and after. If the child is older, the child is also included in this. A number of tests are performed, these tests are not general and are determined according to the patient. The patient is also seen by the anesthesiologist, the family and the child are informed about the anesthesia process to be experienced. The patient is left hungry for 4 hours before the surgery.

Web Will It Reoccur After Surgery?

If the surgery is performed properly and by experienced people, it will not reoccur.

 

*** The information provided here and the content of the website are designed to inform visitors, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. The patient should definitely be examined by a pediatric surgeon on the subject, and a decision should be made by consulting him/her and consulting his/her personal information.