Duodenal Obstruction

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CHAPTER 15 Duodenal Obstruction

Daniel von Allmen

Step 1: Surgical Anatomy

♦ In congenital duodenal atresia, the obstruction is distal to the ampulla of Vater in 85% of patients. A complete obstruction may be a luminal web (most common), an atresia connected by a fibrous cord, or complete separation of proximal and distal segments (Fig. 15-1).

♦ The ampulla is located close to the medial wall of the web, and care must be taken to avoid injuring it during repair.

♦ A fenestrated duodenal web with incomplete obstruction may not be noted at birth but can be seen later with feeding intolerance or obstruction when solid foods are started.

♦ Annular pancreas may accompany duodenal atresia. The annular portion of the pancreas can contain a significant pancreatic duct (Fig. 15-1, D).

♦ A “windsock” deformity can suggest a more distal obstruction (Fig. 15-2).

♦ Esophageal atresia may accompany duodenal atresia.

♦ Preduodenal portal vein may cause obstruction of the duodenum.

♦ Familial duodenal atresia occurs as part of Feingold syndrome.

Figure 15-1

Figure 15-2

Step 2: Preoperative Considerations

♦ The differential diagnosis includes malrotation with volvulus, small bowel atresia, and Hirschsprung disease in patients with bilious vomiting. In patients with nonbilious emesis, the differential includes pyloric atresia and antral web.

♦ Prenatal ultrasound and postnatal plain films show classic “double-bubble” configuration with a dilated first portion of the duodenum (Fig. 15-3).

♦ About 30% of patients with duodenal atresia have trisomy 21.

♦ About 20% of patients with duodenal atresia have cardiac anomalies.

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