A pediatric surgery topic -duodenal atresia Duodenal atresia is the congenital absence or complete closure of a portion of the lumen of the duodenum. It causes increased levels of amniotic fluid during pregnancy (polyhydramnios) and intestinal obstruction in newborn babies

1. DUODENAL ATRESIA
Dr AKSHAY
JR
Department of General surgery
Mch calicut

2. INCIDENCE
• 1 in 6000-10000 live births

3. Embryology
• The endoderm-gut tube-3-4weeks
• 6th week gut epithelium
proliferates rapidly,resulting in
obliteration of the intestinal
lumen—recanalizes in next few
weeks
• Errors in recanalization –primary
cause
• This differs from other atresias-
intrauterine vascular accidents
during the later phases of gestation

4. Associated anomalies
• Down syndrome 28%
• Annular pancreas 23.1%
• Congenital heart disease 22.6%
• Malrotation 19.7%
• EA/TEF 8.5
• Genitourinary 8.0
• Anorectal 4.4
• Other bowel atresia 3.5

5. Gray and Skandalakis Classification
DA
Type1(92%) Type2(1%) Type3(7%)

6. Type 1
• Continuity is maintained,may be
normal on exterior,but obstructed by
a intact membrane or diaphragm
• Wind Sock deformity
• May be totally intact obstructing the
lumen completely
• Traction on the membrane with a
catheter may cause dimpling at the
origin of diaphragm-helps find out
where the membrane starts

7. Wind Sock deformity
• A variant of type1 DA
• Membrane is thin and elongated
• Base of the membrane in D2
• Balloons out distally intp D3 /D4
• Thus externally the obstruction
appears considerably more distal
than it is actually

8. Type 2
• Continuity not maintained,but
connected by a fibrous cord
• Mesentery intact

9. Type 3
• No connection between the
two blind ends of the
duodenum
• V-shaped mesenteric defect

10. Duodenal web
• Perforate/imperforate
wen/septa
• Diameter of the opening
directly determines the degree
of obstruction and is therefore
inversely related to symptoms

11. Site of obstruction
• Commonest D1 and D2 -85%
• Complete-81%
• Incomplete-19%
• Majority(75-95%) is seen distal to ampulla of vater-bilious
emesis,minimal distension
• May asscociated with extrinsic compression –annular pancreas,pre
dudodenal portal vein

12. Clinical features
Antenatally
• Polyhydramnious -50%
• Double bubble
Postnatal
• Bilious emesis from birth
• May be blood stained
• Epigastric distension,dehydration,emaciation
• Downs facies

13. Delayed presentation
• Recurrent vomiting
• Fb/food bolus impaction
• Failure to thrive

14. Diagnosis
• A/N-USG-double bubble sign-due to
fluid
• P/N-Xray-Double bubble sign –due
to air
If inconclusive
Inject 30-60ml air –repeat plain xray
Or a Contrast study

15. Preoperative preperation
• Ng tube decompression
• Replace GI loses
• PICC line
• TPN-(gastroperasis due to chronic obstruction)

16. Surgery-technique
• KIMURA’S diamond shaped DUODENO DUODENOSTOMY-Trans
anastomotic fedding tube

17. • Webs are excised without injuring ampulla of vater
• Other techniques
• Tapering duodenoplasty+anastomosis
• Duodenojejunostomy

18. Per operative
• Rule out distal atresia-using 6fr foleys catheter
• Rule out malrotation
• Donot miss out wind sock deformity

19. Post operative complications
• Prolonged gastroparesis-2-3 weeks to subside-use of prokinetic –
erythromycin in suboptimal dose (10mg/kg/dose)
• Anastomotic leak
• Anastamotic stricture-endoscopic dilataion

20. Outcome
• 45-95% survival
• Outcome depends on associated major anamolies

21. Thank you