A rare occurrence of multiple intestinal atresias, with successful one-procedure resection and primary anastomosis.

SUMMARY: Intestinal atresia is a common cause of neonatal bowel obstruction. Many theories exist relating to intestinal atresia, though the best explanation is related to vascular events. Duodenal atresia is thought to be due to a developmental anomaly of the intestine. A rare combination of concomitant Type III duodenal atresia, Type III B jejunal atresia, and Type I ileal atresia is presented. The differing pathogenesis of these atresias makes the condition exceptionally rare. This patient was successfully treated, via explorative laparotomy, with resection of the atretic segments and two primary anastomoses, without the need for enterostomies or stents.

Laparoscopic Versus Open Surgical Repair of Duodenal Atresia: A NSQIP-Pediatric Analysis.

INTRODUCTION: Laparoscopic repair of duodenal atresia in neonates has gained popularity among some pediatric surgeons. Single-center studies suggest comparable short-term outcomes to open surgery. The purpose of this study was to utilize a large, multi-institutional pediatric dataset to examine 30-day post-operative outcomes by operative approach for newborns who underwent duodenal atresia repairs. METHODS: We identified neonates aged ≤1 wk in the 2016-2018 National Surgical Quality Improvement Program-Pediatric -database that underwent a laparoscopic or open repair for duodenal atresia. Preoperative characteristics were compared between operative approaches. Postoperative complications, operative time, postoperative length of stay (LOS), and supplemental nutrition at discharge were assessed using multivariate regressions. RESULTS: There were 267 neonates who met inclusion criteria. There were 233 (87%) infants who underwent open repairs and 34 (13%) who underwent laparoscopic repairs. Ten (29%) children who had laparoscopy were converted to open. After adjusting for confounding, laparoscopy was associated with an increase in operative time by 65 min (95% confidence interval 45-87 min, P < 0.001) but a five-day shorter LOS (95% confidence interval -9 to -2, P = 0.006) when compared to laparotomy. There were no significant differences in postoperative complications or supplemental nutrition at discharge. CONCLUSIONS: Our findings suggest that laparoscopic repairs of duodenal atresia are associated with shorter postoperative LOS but longer operative times when compared to open repairs. Although the conversion rate to laparotomy remained relatively high, the laparoscopic approach was associated with comparable 30-day postoperative outcomes.

An unexpected cause of proximal small intestinal obstruction.

A 63-year-old caucasian male with history of tonsil cancer, under induction chemotherapy, reported food intolerance and vomiting with duration of one month. Symptoms had increased over the last days and were associated with a weight loss of 10 Kg during the past three months. The patient lived all of is life in an urban environment. General physical examination revealed cachexia and dehydration. Gastrointestinal symptoms persisted despite intravenous pantoprazole, prokinetic drugs and nasogastric tube insertion. On investigation, patient presented normocytic and normochromic anemia (9.2 g/dL), lymphocytosis (11.78 x109/L) with neutrophilia (70.7%) and eosinophilia (7.7%), hypoalbuminemia (2.8 g/dL) and elevated C-reactive protein (25.5 mg/dL). Upper endoscopy revealed deformation of bulb and second part of the duodenum with mucosal edema, superficial ulceration and friability (Figure 1a). Biopsies were taken from the bulb and second portion of the duodenum. Computer tomography demonstrated gastric distention, duodenal wall thickening and lumen narrowing in the second and third portion of the duodenum (Figure 2). These findings were indicative of a functionally relevant duodenum stenosis. Histopathologic evaluation of biopsy specimens from the duodenum revealed moderate accumulation of eosinophilic granulocytes and nematode larvae within mucosal crypts (Figure 1b). What is the diagnosis?

Duodenoyeyunostomía laparoscópica en el Síndrome de la Arteria Mesentérica Superior / Laparoscopic duodenojejunostomy for Superior Mesenteric Artery Syndrome

Introducción: El Síndrome de la Arteria Mesentérica Superior es causa poco frecuente de obstrucción duodenal. Los síntomas varían desde una obstrucción leve hasta emergencias agudas. El examen físico no siempre ayuda al diagnóstico, que se basa en los hallazgos imagenológicos. Objetivo: preconizar, recomendar el uso de las técnicas mínimamente invasivas en el manejo quirúrgico del Síndrome de la Arteria Mesentérica Superior. Presentación del caso: Mujer de 49 años de edad, antecedentes de pérdida de peso después de quimioterapia con náuseas, vómitos y dolor abdominal posprandial de dos años de evolución. Tratada exitosamente con duodenoyeyunostomía laparoscópica. El tratamiento inicial suele ser conservador. Publicaciones recientes respaldan que la duodenoyeyunostomía laparoscópica es un método seguro y efectivo para su tratamiento. Conclusiones: El tratamiento quirúrgico es cada vez más exitoso, la mayoría de los pacientes no presenta síntomas después de la cirugía(AU)

Introduction: Superior Mesenteric Artery Syndrome is an uncommon cause of duodenal obstruction. Symptoms may vary from mild obstruction to acute life-threatening emergencies. Physical examination does not always help in establishing the diagnosis which is based on findings from imaging studies. Objective: To recommend the laparoscopic approach for the surgical treatment of this entity. Case presentation: A 49-year old female patient with prior history of weight loss after chemotherapy and a two-year history of postprandial nausea, vomiting, and abdominal pain who was successfully treated by laparoscopic duodenojejunostomy is presented. Discussion: Initial treatment is usually conservative. Recently published studies support that laparoscopic duodenojejunostomy is a safe and effective method of treatment. Conclusions: Surgical treatment is becoming more successful and the majority of patients are symptom-free after surgery(AU)

The risk factors for cholestasis in patients with duodenal atresia in a single institutional cohort.

PURPOSE: The etiology of cholestasis in neonates is associated with several factors including gastrointestinal disease and surgery. We aimed to identify the potential risk factors for perioperative cholestasis in patients with duodenal atresia and determine specific cutoff values for the risk factors. METHODS: This retrospective cohort study included 76 neonates diagnosed with duodenal atresia surgically treated during the neonatal period at our institution between January 1990 and March 2017. The neonates were categorized into two groups: those with and without cholestasis. Univariate and multivariate analyses were performed to identify the possible risk factors for cholestasis. RESULTS: Among the 76 neonates with duodenal atresia, 21 (27%) developed cholestasis. The duration of total parenteral nutrition was identified as a risk factor in univariate analysis; however, it was not an independent risk factor for cholestasis. Gestational age and highest C-reactive protein (CRP) values were independent risk factors, with adjusted odds ratios of 0.53 and 1.25, respectively. To predict the occurrence of cholestasis, the cutoff value for gestational age was 35.0 weeks, and highest CRP value was 2.4 mg/dL. CONCLUSIONS: The occurrence of cholestasis in patients with duodenal atresia was associated with preterm delivery and severity of the inflammatory response during the perioperative period.

Management of duodenal atresia associated with situs inversus abdominus: A case report.

RATIONALE: Duodenal atresia in association with situs inversus abdominus is extremely rare. Care should be taken when selecting appropriate surgical methods, and caution should be exercised during the surgery to avoid misdiagnosis and mistreatment. With prompt recognition of the condition, the surgical procedure should be performed in a timely manner to achieve positive results. PATIENT CONCERNS: A newborn affected by situs inversus abdominus associated with duodenal atresia, midgut malrotation, and volvulus. DIAGNOSIS: Congenital duodenal atresia with situs inversus abdominis. INTERVENTIONS: Diamond-shaped duodenoduodenostomy with appendectomy was performed, with the release of Ladd band and correction of the malrotation. OUTCOMES: The baby boy is thriving well with no abdominal complaints at 4 years of surgical follow-up. LESSONS: Although several theories are put forward to clarify this matter, the proper cause of duodenal atresia is not well defined. Clinical symptoms and examinations can assist diagnosis, the definitive cause should be ascertained by surgical approach. And the operating surgeon must be aware of the "mirror anatomy" to prevent unnecessary injuries. Additionally, long-term prognosis for duodenal atresia are very good, therefore, careful attention in postoperative management are important in such a case.

Erodes and bleeds, fistulises and obstructs: Bouveret's syndrome.

One of the rare complications of cholelithiasis is gallstone ileus which occurs in <5% of patients. Among them, <3% develop Bouveret's syndrome: gastric outlet obstruction by a large gallstone in the pylorus or duodenum. One large review of 128 patients showed it to present at a mean age of 74.1 ± 11.1 years with a mean gallstone size of 4.6 ± 1.5 cm, with nausea or vomiting in 86%, abdominal pain in 71% and haematemesis in 15%. The diagnosis is usually clear on oesophagogastroduodenoscopy or abdominal contrast-enhanced computed tomography. We present a case with massive upper gastrointestinal bleeding, due to erosion of a cystic artery pseudoaneurysm.

Obstructive jaundice caused by ulcerative duodenal stenosis: A case report.

A peptic ulcer is a rare cause of distal common bile duct stricture, Obstructive jaundice as a complication of ulcerative duodenal stenosis is quite difficult to differentiate from malignant disease, especially in those in which esophagogastroduodenoscopy examination does not reveal an ulcer. In this case report, a 61-year-old male suffered from right upper quadrant pain, chills and fever caused by duodenal and distal common bile duct stenosis originating from ulcer and was treated surgically.

Bouveret´s syndrome: a rarest complication of cholelithiasis. A case report and literature review.

Bouveret´s syndrome refers to the condition of gastric outlet obstruction caused by the impaction of a large gallstone into the duodenum after passage through a cholecystoduodenal fistula. Many endoscopic and surgical techniques have been described in the management of this syndrome, however the morbidity and mortality are still very high. We present the case of a 67-year-old female patient with Bouveret´s syndrome, with successful resolution with surgical treatment after two failed endoscopic treatments.

El síndrome de Bouveret se refiere a la obstrucción de la salida gástrica causada por un lito grande impactado en el duodeno que pasó a través de una fístula colecistoduodenal. Se han descrito varias técnicas endoscópicas y quirúrgicas para tratar esta entidad, pero la morbimortalidad es aún muy elevada. Se presenta el caso de una paciente femenina de 67 años con síndrome de Bouveret, con exitosa resolución mediante tratamiento quirúrgico posterior a dos tratamientos endoscópicos fallidos.

The natural progression of a fistulizing gallstone resulting in massive gastrointestinal hemorrhage and Bouveret syndrome, a rare case.

Gallstones are seen very common, especially in the Western World. While most patients are asymptomatic, gallstones can cause life-threatening complications. Here, we present a rare and nearly fatal complication of gallstones, showing the natural progression of gallstone disease. With two very unusual complications of gallstones which occurred in the same patient. Massive gastrointestinal bleeding, and the Bouveret syndrome.

Potential Benefits of Laparoscopic Repair of Duodenal Atresia: Insights from a Retrospective Comparative Study.

INTRODUCTION: Congenital duodenal obstruction (CDO) repair can be performed open or laparoscopically. We aimed to determine the potential benefit of laparoscopic repair regarding tolerance of enteral feeding, postoperative pain, hospital stay, and complication rate. MATERIALS AND METHODS: In a single-center retrospective cohort study, we compared neonates with isolated CDO operated open versus laparoscopically from 2010 to 2019. No transanastomotic tubes were used, and anastomoses were created in a side-to-side fashion in all cases. An early feeding policy is applied for all cases operated at our institution. Statistical comparison was performed using the Mann-Whitney's test or Fisher's exact test where appropriate. RESULTS: Forty-one patients analyzed were similar regarding body weight, gestational age, and proportion of patients with trisomy 21. Median follow-up was 21 months. Four (20%) out of 20 laparoscopic procedures started laparoscopically were converted to open. Comparing the 21 open with the 16 laparoscopically completed patients, median anesthetic duration was shorter by 18% in the open versus laparoscopic completed group (218 vs. 179 minutes, respectively; p = 0.025). Median postoperative time to full enteral feeds was shorter by 4 days in the first group (7 vs. 11 days, respectively; p = 0.028). In accordance, the median duration of parenteral nutrition (PN) was less than half in the laparoscopic completed compared with the open group (5 vs. 11.5 days, respectively; p = 0.031). Postoperative opioids were required for only half the duration in the laparoscopically completed group compared with open (2 vs. 4 days, respectively; p = 0.026). Outcomes such as length of stay, the occurrence of strictures or adhesions requiring reintervention, or line sepsis were similar in both groups. CONCLUSION: Patients undergoing laparoscopic CDO repair at our institution benefited from shorter time to full enteral feeds, and reduced the need for PN as well as postoperative pain medication.

Encysted hydrocele of the canal of Nuck in an 11-month-old child with a past history of duodenal atresia and Arnold-Chiari malformation: A case report.

RATIONALE: Hydrocele of the canal of Nuck is a rare developmental disorder and represents of a homolog of hydrocele of spermatic cord in males. Hydrocele of the canal of Nuck is a very rare cause of inguinal swelling in female infants and children. It results from the failure of obliteration of the distal portion of evaginated parietal peritoneum within the inguinal canal, which forms a sac containing fluid. PATIENT CONCERNS: We describe a case of hydrocele of the canal of Nuck in an 11-month-old girl with a past medical history of duodenal atresia and Arnold-Chiari malformation. DIAGNOSIS: Physical examination and ultrasound revealed a soft, cystic, noncompressible, and non-fluctuant labial mass measuring approximately 5 cm. INTERVENTIONS: The patient underwent surgical exploration through a right skin crease incision. The cystic lesion was histologically confirmed to be a non-communicated hydrocele of canal of Nuck. OUTCOMES: The child is doing well at 1-year follow-up with no swelling or recurrence on the operated side. LESSONS: Hydrocele of the canal of Nuck is a rare developmental disorder but should be considered in a differential diagnosis in young girls with an inguino-labial swelling.

Acute mechanical duodenal obstruction due to giant hydronephrosis: an unusual cause of acute abdomen.

Giant hydronephrosis (GH) is a rare clinical entity with about 600 cases and defined as the adult renal pelvis containing greater than 1 L of fluid, or at least 1.6% of the body weight or kidney occupying the hemiabdomen. The pelvic-ureteric junction (PUJ) obstruction is the most frequent cause of GH. We thus report a case of massive abdominal distension due to GH secondary to PUJ obstruction who presented with acute duodenal obstruction due to extrinsic compression and was managed with percutaneous nephrostomy followed by open nephrectomy.

Megaduodenum in a 59-year-old man: a very late postoperative complication after duodenal atresia.

Intestinal malformations are common defects of the newborn, treated in experienced centres. Reports on long-term follow-up and associated complications are scarce, possibly leading to misinterpretation of clinical signs and symptoms in adulthood. To prevent treatment errors, it is important that physicians are aware of long-term complications of intestinal malformations.

Case report of a congenital duodenal transverse septum causing partial obstruction.

INTRODUCTION: Duodenal obstructions caused by congenital anatomic abnormalities are rare in adults. Several patients in whom the duodenal obstruction was caused by a congenital duodenal diaphragm have been described. The duodenal obstruction in the patient presented herein was caused by a transverse septum, which has not been previously reported. A transverse septum is usually observed in the vagina; those involving the digestive tract have been rarely observed. CASE PRESENTATION: We herein report a case involving a 69-year-old woman with a congenital duodenal transverse septum causing partial obstruction. She was admitted to our hospital with a 3-month history of epigastric pain and vomiting. Upper gastrointestinal endoscopy, iodinated water-soluble contrast imaging, and abdominal computed tomography revealed dilation of the stomach and a neoplasm in the descending part of the duodenum. The patient was suspected to have a tumor in the descending part of the duodenum. Exploratory laparotomy showed a banded duodenal transverse septum at the junction of the second part of the duodenum. The duodenal transverse septum was approximately 2 mm thick and 1 cm wide and divided the duodenal lumen into 2 parts. The duodenal papillae were completely normal and located under the duodenal transverse septum. Histopathological analysis of the transverse septum showed that it was similar to the organizational structure of the duodenal wall. CONCLUSION: The possibility of congenital disease should be considered in older patients with intestinal obstruction, even when imaging studies reveal a duodenal neoplasm.

Gallstone ileus of the duodenum: an unexpected presentation of Bouveret's syndrome.

This report describes a patient who presented with a large gallstone obstructing the duodenal bulb, with the chief complaint of acute on chronic abdominal pain. Classically, this is known as Bouveret's syndrome or a gallstone ileus of the duodenum. Our patient's current health status presented a challenge, with the presence of several comorbidities, particularly a large abdominal aortic aneurism. We chose an open procedure for this reason. The stone was removed through a laparotomy, and the cholecystoduodenal fistula that the stone used to pass into the small bowel was repaired. With our patient's future medical needs in mind, only the necessary interventions were performed to regain functionality of the bowel. This came in the form of a diverting gastrojejunostomy, with a distal jejunostomy and feeding tube inserted. The patient tolerated the procedure well, only remaining intubated postoperative due to her chronic obstructive pulmonary disease (COPD). She achieved a complete recovery and transitioned home.

Increase body weight to treat superior mesenteric artery syndrome.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction resulting from vascular compression of the third part of the duodenum in the angle between the abdominal aorta and SMA. CASE PRESENTATION: A 19-year-old woman with anorexia nervosa with upper gastrointestinal obstruction symptoms resorted to the emergency department. A diagnosis of SMA syndrome was made. Symptoms were solved with conservative treatment aimed at increase body weight. DISCUSSION: SMA syndrome is most commonly associated with debilitating illnesses. Patients present with acute or insidious upper gastrointestinal obstruction symptoms. Aortomesenteric artery angle of ≤25° is the most sensitive measure of diagnosis. Advances in both enteral and parenteral nutrition led to a shift towards conservative treatment. CONCLUSIONS: Low threshold of suspicion is important to make a timely diagnosis and treatment. A conservative treatment aimed at increasing body weight is the first-line approach, leaving surgical intervention for failure cases.