Introduction
The first reports of laparoscopic repair of duodenal atresia date from the beginning of the twenty-first century, when shortly after each other Bax et al. [
1], and Rothenberg [
2] described their initial experience with the novel procedure. Normally after such publications other reports follow on similar successful techniques and larger series are presented. However, not in this case: a scant case report here and there, but nothing more. Then, in 2007 and 2008 a Kansas group reported first results with an alternative technique using U-clips, because of “unacceptably” high rates of leakage with the original procedure [
3,
4].
Because our initial experience with the technique of laparoscopic repair of duodenal atresia was not satisfactory, the laparoscopic approach was discontinued in 2005. Only after gaining considerabe experience with intracorporeal suturing and making adjustments to the operative technique we restarted use of the laparoscopic procedure in 2008. In this article we revisit the outcome of laparoscopic repair of duodenal atresia.
Results
The demographics of the two groups were comparable. In group 1 there were four conversions (Table
1). In group 2 there were no conversions anymore. There were no intraoperative complications, but in group 1 five patients developed postoperative leakage. In two patients with both esophageal and duodenal atresia, the repairs were accomplished endoscopically, and leakage occurred after accidental extubation and reintubation in the esophagus on day 3 in one child and on day 10 in the second. One patient turned out to have a total aganglionic colon, causing blow- out of the anastomosis. In one patient at laparoscopic re-exploration a single additional suture was necessary for complete closure. Most leaks occurred on the posterior side.
In one patient a redo operation was necessary for recurrent stenosis of the anastomosis. In that patient it was believed that electrocautery was the cause for excessive cicatrization. In group 2 there were no postoperative complications. Oral feeding was started 2–4 days postoperatively and all children were on total oral nutrition 5–8 days postoperatively (Table
1), except for the child with Down syndrome who required 10 days to total oral feeding.
The follow-up is now between 6 months and 2½ years and no further complication have been noted.
Discussion
“Long-term follow-up is necessary” is an oft-heard conclusion after initial reports of new techniques. This certainly was true for the laparoscopic repair of duodenal atresia.
After our initial report, we enthusiastically proceeded to treat our patients laparoscopically. However, on evaluation of the results in 2005, we found the complication rate unacceptably high and abandoned the laparoscopic approach in order to examine the procedure. It was obvious that most leakages occurred at the posterior side of the anastomosis. Apparently estimation of the distance between the separate sutures is difficult. Making a running suture forecloses this risk. Also, when using the distal suture as a stay suture, this stabilizes the anastomosis, and pulling on the short end of the proximal suture brings the two ends of the intestine into parallel, facilitating the anastomosis of the posterior wall. This change of technique improved the quality of the anastomosis, and no further leakages have occurred. This modified technique is now also used for repair of esophageal atresia.
That leakage apparently was not an uncommon complication was indirectly confirmed when another group presented an alternative technique using U-clips [
3,
4]. After they described the technique, they presented a series of 29 patients with congenital duodenal obstruction, where they compared the open and laparoscopic technique between 2003 and 2008. Although not noted in their article, as the first description of the technique dates from July 2006, it can be assumed that they started the new technique as of 2006 and that all the patients undergoing operation prior to that date were treated by the open technique.
More recently, Rothenberg’s group also presented their follow-up [
5] and again there was a time lapse between the first report, where four patients were described operated on between March and July 2001, and the second report that describes a patient group operated on between January 2004 and January 2008. The good results they achieved may well be due to the fact that in a number of patients they used the continuous suture technique. It appears that this technique provides a more watertight closure and does not induce anastomotic stenosis, as might be feared by some surgeons.
Laparoscopic repair of duodenal atresia is a very elegant way of restoring continuity of the duodenum. The patient seems to benefit from the laparoscopic approach, because recovery is quick and oral feeding resumes earlier, leading to a quick return to a full oral diet and discharge, as was shown in this series. Similar results have been reported by others [
4].
It is important to note that all results obtained so far have been reported by very experienced pediatric endoscopic surgical groups. In an era when governments, patient groups, insurance companies, and medical societies are all applying increasing pressure to provide quality care by concentrating specific procedures in “large quantity and quality centers,” the laparoscopic repair of duodenal atresia—and, in this sense, perhaps esophageal atresia as well—should be limited to designated centers with extensive experience in pediatric endoscopic suturing.
In conclusion, in revisiting the laparoscopic repair of duodenal atresia, it has become clear that laparoscopic treatment should be restricted to a limited number of designated centers of expertise.
Open Access
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