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Duodenal Atresia and Stenosis 383

For side-to-side anastomosis, interrupted Lembert sutures (4-0
or 5-0 vicryl or monocryl) start the dorsal part of anastomosis if a
two-layer closure is desired. A transverse duodenotomy is made in
the proximal segment, 1 cm above the stenosis, to avoid injury of the
pancreatico-biliary system. Easy retrograde passage of a tube into the
stomach rules out a duodenal web proximal to the duodenotomy. A
parallel incision is made in the distal duodenum. The posterior layer of
anastomosis is completed by inverting interrupted or continuous sutures
of 4-0 or 5-0 vicryl or monocryl. A transanastomotic nasoduodenal
silicone tube can be inserted to allow very early enteral feeding
beginning at day one or two after surgery. The anterior layer of the
anastomosis is completed in the same way. A few Lembert sutures may
be used to complete the anastomosis.
For diamond-shaped duodenoduodenostomy, a little more Figure 62.4: Diamond-shaped duodenoduodenostomy.
mobilization is needed to bring the redundant proximal duodenal wall
down to overlie the proximal portion of the distal segment. Then a
transverse incision in the proximal and a longitudinal incision in the
distal duodenum are made. The papilla of Vater is located by gentle
pressure on the gallbladder. Stay sutures approximate the parts in
corresponding points, as shown in Figure 62.4, and the remainder of the
anastomosis and placement of a transanastomotic tube is carried out as
previously described. Figure 62.5 shows intraoperative photos before
and after duodenoduodenostomy.
For a duodenal web, the membrane is usually located in the second
part of the duodenum. Localization of the membrane can be assisted
by passage of a nasogastric tube (NGT) into the duodenum down to
the level of the membrane. Care is to be taken to identify the so-called
wind-sock phenomenon, which refers to a proximally attached, lax
membrane that bulges into the distal duodenum, making the obstruction
point appear more distal than it actually is. This can be identified by
looking for a dimpling of the duodenal wall at the attachment point of
the membrane more proximal than the distal tip of the NGT.
For membrane resection, a longitudinal incision is made, bridging
between the wide and the narrow segments, or at the level of duodenal
attachment of the membrane in the case of a wind-sock deformity. It
is important to note that the ampulla of Vater may open directly into
any membrane or close to it in its posterior-medial part. Therefore,
identification of the ampulla is mandatory before excision of the
membrane. Excision begins with a radial incision starting in the central
ostium and leaving a rim of 1–2 mm of tissue at the duodenal wall.
Once again, great care is to be taken to avoid damage to the ampulla
of Vater. The resection line is oversewn with continuous suture vicryl
5-0. Before closing the duodenum transversely, patency of the distal
duodenum is to be proven with a small silicon catheter and saline.
Postoperative Considerations and
Complications
Intravenous infusions are continued for the postoperative period. Using
a transanastomotic tube laying deep in the jejunum, feeding can be
started as early as 48 hours postoperatively. Where available, paren-
teral nutrition via a central or peripherally inserted catheter can be very
effective for longer-term nutritional support if transanastomotic enteral
feeding is inadequate, not feasible, or not tolerated by the patient. All
patients have a prolonged period of bile-stained gastric aspirate. This is
mainly due to the ineffective peristalsis of the distended upper duode-
num. The commencement of oral feeding is dependent upon a decrease
in the volume of gastric aspirate and is often delayed for up to several Figure 62.5: Intraoperative photo of duodenal atresia before (top) and
weeks. Patients who have a severely prolonged return of duodenal after (bottom) duodenoduodenostomy.
function and have exceptionally marked dilatation of the proximal
duodenum may benefit from reoperation and tapering of the proximal
segment, although this is rare.
Anastomotic leak, intraabdominal sepsis, and wound complications
also are rare.