The surgical correction of duodenal atresia is by:
a. Whenever the diagnosis of duodenal obstruction is entertained, malrotation and midgut volvulus must be excluded. This topic is covered in further detail below.
b. Other causes of duodenal obstruction include duodenal atresia, duodenal web, stenosis, annular pancreas, or duodenal duplication cyst.
c. Duodenal obstruction is easily diagnosed on prenatal ultrasound, which demonstrates the fluid-filled stomach and proximal duodenum as two discrete cystic structures in the upper abdomen.
d. Associated polyhydramnios is common and presents in the third trimester.
e. In 85% of infants with duodenal obstruction, the entry of the bile duct is proximal to the level of obstruction, such that vomiting is bilious.
f. Approximately one-third of newborns with duodenal atresia have associated Down syndrome (trisomy 21).
g. Patients then should be evaluated for associated cardiac anomalies.
h. Once the work-up is complete and the infant is stable, the patient is taken to the operating room and the abdomen is entered through a transverse right upper quadrant supraumbilical incision under general endotracheal anesthesia.
i. Associated anomalies should be sought at the time of the operation. These include malrotation, anterior portal vein, a second distal web, and biliary atresia.
j. The surgical treatment of choice for duodenal obstruction due to duodenal stenosis or atresia or annular pancreas is a duodenoduodenostomy.
k. In cases in which the duodenum is extremely dilated, the lumen may be tapered using a linear stapler with a large Foley catheter (24F) in the duodenal lumen.
l. It is important to emphasize that an annular pancreas is never divided. Treatment of duodenal web includes vertical duodenotomy, excision of the web, oversewing of the mucosa, and closing the duodenotomy horizontally.
m. Late complications from repair of duodenal atresia occur in approximately 12 to 15% of patients, and include megaduodenum, intestinal motility disorders, and gastroesophageal reflux.