|Year : 2019 | Volume
| Issue : 2 | Page : 75-78
Retrocolic isoperistaltic gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in low- and very low-birth-weight babies of duodenal atresia: A 5 year retrospective study
Apoorva Kulkarni, Abhaya Gupta, Paras Kothari, Shalika Jayaswal, Vishesh Dikshit, Geeta Kekre
Department of Pediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||25-Apr-2019|
Dr. Abhaya Gupta
Department of Pediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Duodenal atresia is a frequent occurrence in babies requiring emergent surgical intervention. Conventionally, Kimura's diamond duodenoduodenostomy has been considered as the gold standard. However, in low-birth-weight (LBW), very LBW (VLBW), and extremely LBW (ELBW) babies, we have found it to be a procedure that is not well tolerated and resulted in mortality. In these conditions, a retrocolic isoperistaltic gastrojejunostomy is well tolerated by patients. Most of the patients that public hospitals cater to are from the lower socioeconomic strata belonging to poor families, immigrant population, and daily wagers. Aim: The aim of the study is to evaluate gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in LBW, VLBW, and ELBW neonates having duodenal atresia without major cardiac malformations. Materials and Methods: We did a retrospective analysis of all patients with birth weight <2 kg operated for duodenal atresia in our institute in the last 5 years (2012–2017). Neonates having cardiac abnormality were excluded from the study. Patients were followed up regularly. Results: Out of 5 neonates operated for gastrojejunostomy, all survived postoperatively. Out of 4 neonates operated for Kimura's duodenoduodenostomy, none survived postoperatively. Most common cause of mortality was sepsis and anastomotic leak. Conclusion: In a setting of LBW and VLBW deliveries, gastrojejunostomy is a good alternative to duodenoduodenostomy achieving favorable results.
Keywords: Duodenal atresia, duodenoduodenostomy, gastrojejunostomy, low birth weight, very low birth weight
|How to cite this article:|
Kulkarni A, Gupta A, Kothari P, Jayaswal S, Dikshit V, Kekre G. Retrocolic isoperistaltic gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in low- and very low-birth-weight babies of duodenal atresia: A 5 year retrospective study. J Clin Neonatol 2019;8:75-8
|How to cite this URL:|
Kulkarni A, Gupta A, Kothari P, Jayaswal S, Dikshit V, Kekre G. Retrocolic isoperistaltic gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in low- and very low-birth-weight babies of duodenal atresia: A 5 year retrospective study. J Clin Neonatol [serial online] 2019 [cited 2019 Oct 22];8:75-8. Available from: http://www.jcnonweb.com/text.asp?2019/8/2/75/257143
| Introduction|| |
The first reported case of duodenal atresia is attributed to Calder in 1773. Since then, it has been one of the most common causes of neonatal intestinal obstruction. The estimated incidence is between 1 in 6000 and 10,000 live births. It is associated with other congenital anomalies such as annular pancreas, intestinal malrotation, esophageal atresia, Meckel's diverticulum, and various other cardiac, renal, and central nervous system anomalies. Down's syndrome is an association in 30% of cases.
Conventionally, a Kimura's diamond duodenoduodenostomy has been considered the standard surgical procedure. We have evaluated gastrojejunostomy as an alternative in low birth weight (LBW) and very LBW (VLBW) babies.
| Background|| |
Most of the patients that public hospitals cater to are from the lower socioeconomic strata. Most of the patients belong to poor families, immigrant population, and daily wagers. These patients come from villages where tertiary care centers are not affordable/available. Undernutrition and illiteracy is prevalent among the pregnant mothers. Prolonged hospital stay and expensive treatment affects not only their finances but also their family structure and livelihood. Knowing these factors, we tried to treat these patients with options that would give us the best possible outcome.
Aims and objectives
The aim of the study is to evaluate retrocolic isoperistaltic gastrojejunostomy as an alternative to Kimura's duodenoduodenostomy in LBW, VLBW, and ELBW neonates having duodenal atresia without major cardiac malformations.
| Materials and Methods|| |
We did a retrospective analysis of all patients with birth weight <2 kg operated for duodenal atresia at our institute in the last 5 years (2012–2017). Four patients had undergone Kimura's duodenoduodenostomy and five patients underwent gastrojejunostomy. Our inclusion and exclusion criteria for the study were as follows:
- All neonates with duodenal atresia having birth weight <2 kg
- Cardiac evaluation found to be normal.
- All neonates with duodenal atresia having birth weight more than 2 kg
- Any cardiac abnormality found on two-dimensional (2D) echocardiography
- Any concomitant congenital abnormality such as malrotation and esophageal atresia, with the exception of Down's syndrome.
After doing the data analysis, the results were compiled in tabular form. Patients were followed up at regular intervals and were evaluated for adequate weight gain and any other complaints.
| Results|| |
A total of nine LBW, VLBW, and ELBW neonates were operated for duodenal atresia in the past 5 years [Table 1]. Kimura's duodenoduodenostomy being the gold standard was performed in all patients of duodenal atresia. However, over a period of time, we realized that duodenoduodenostomy (n = 4) resulted in a high rate of complications and mortality in LBW and VLBW babies. The most common causes were neonatal sepsis and anastomotic leak. None of the LBW and VLBW babies in whom we performed Kimura's duodenoduodenostomy survived postoperatively.
|Table 1: Comparison between results of duodenoduodenostomy and gastrojejunostomy|
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On the other hand, patients undergoing gastrojejunostomy (n = 5) received total parenteral nutrition (TPN) for an average period of 8 days, with the longest being 15 days for a neonate who was operated at a weight of 950 g (ELBW). Neonates in the 1–1.5 kg and 1.5–2 kg groups received TPN for an average of 7 and 6 days, respectively. The time to start feeds was also early with an average of 6.4 days, with the maximum time of 12 days required for the neonate weighing 950 g. All patients who underwent gastrojejunostomy survived. Patients were discharged after achieving adequate weight gain, thereby increasing the hospital stay.
Hence, we started performing the retrocolic isoperistaltic gastrojejunostomy as an alternative procedure in LBW, VLBW, and ELBW babies. There were no cases of anastomotic leak in these patients. Out of the 4 patients who expired after Kimura's duodenoduodenostomy, 2 patients had anastomotic leak, whereas 2 others died of neonatal sepsis.
Cardiac evaluation was done in all patients. Detailed 2D echocardiography was done during the hospital stay. One patient who underwent gastrojejunostomy had features of Down's syndrome.
All patients were seen at 1 month, 3 months, and 6 months interval after discharge. Weight gain was recorded. All patients have adequate weight gain with no symptoms suggestive of blind loop syndrome.
On long-term follow-up, 2 patients are now 1½ years of age, one patient is 3 years of age, and 2 others are 5 years of age currently. All had adequate weight gain for their age, but never had any abdominal distension or melena.
| Discussion|| |
The general postoperative mortality rate in duodenal atresia is about 4% to 5%. Mortality rate is higher in patients having Down's syndrome and other associated congenital anomalies, especially cardiac defects. The other causes of early postoperative mortality are sepsis, anastomotic leak, and complications related to TPN.
Kimura's duodenoduodenostomy has been the standard surgical procedure for duodenal atresia. It has achieved good results in many series for many years. We have also had good results with this technique in neonates with birth weight over 2.5 kg, with a survival rate of 95%. There has also been a modification to this technique by Zuccarello et al. in 2009, which has also been successful. However, there has not been any study done for similar techniques in LBW and VLBW babies. These babies have problems such as neonatal sepsis and necrotizing enterocolitis which predisposes them to anastomotic leaks, increasing their morbidity and mortality.
Most of the patients that our tertiary care center caters to, are LBW neonates born to malnourished mothers from poor families. There are approximately 1400 LBW babies born annually in our institute. Hence, the hospital caters to a large number of preterm and LBW neonates.
Keeping these above factors in mind and with our experience of high prevalence of neonatal sepsis and anastomotic leak in LBW neonates under surgeries in general, we have shifted our strategy to operative management at an early stage with isoperistaltic retrocolic gastrojejunostomy. Before the mid-1970s, the procedure of choice was duodenojejunostomy. A gastrojejunostomy was rarely performed.,, Patients undergoing duodenojejunostomy required a transanastomotic stent and TPN and also developed blind loop syndrome warranting resurgery in some cases., Blind loop syndrome causes chronic on and off diarrhea and weight loss.
We have chosen gastrojejunostomy as the surgical technique of choice as it is the easiest, fastest, and safest to perform; anatomically feasible; and hence requires the least anesthesia time, which gives the neonate the best chance for postoperative recovery. The duodenum is not handled in this surgery, avoiding duodenal ileus, leading to early start of feeds. Furthermore, we think that mobilization of the duodenum for duodenoduodenostomy in these LBW and VLBW neonates might compromise the blood supply, leading to anastomotic leak, although no anastomotic leak was encountered in any of our patients operated for Kimura's duodenoduodenostomy. Although the number of patients is small, we have not encountered any anastomotic leak in gastrojejunostomy in our patients. None of our patients had blind loop syndrome. Feeds were started early as well. The average hospital stay turned out to be 28 days, most of which were postoperative period to achieve adequate weight gain. Long-term follow-up for these patients is essential.
| Conclusion|| |
In a setting where LBW deliveries are common and parents are from low socioeconomic families, predisposing neonates to neonatal sepsis, surgical management by gastrojejunostomy is a good alternative for achieving favorable results.
Written informed consent
A written informed consent was obtained from the parents of all patients.
The authors would like to acknowledge the Departments of Neonatology and Anesthesia, LTMMC and GH and Dean, LTMMC and GH.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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