What is the most appropriate operation for a neonate with bilious vomiting and a double-bubble sign on plain x-ray, indicative of duodenal obstruction?

Duodenoduodenostomy is the Most Appropriate Operation for a Neonate with Bilious Vomiting and Double-Bubble Sign

The most appropriate operation for a neonate with bilious vomiting and a double-bubble sign on plain x-ray is duodenoduodenostomy (option c). This surgical approach directly addresses the underlying duodenal obstruction that is indicated by these classic clinical and radiographic findings.

Diagnostic Significance of the Double-Bubble Sign

The double-bubble sign on plain x-ray is highly specific for duodenal obstruction. According to the American College of Radiology guidelines:

• The double bubble with no gas distally indicates obstruction of the duodenum, with duodenal atresia being the most common etiology 1
• In a study of 50 neonates with duodenal obstruction, 35 had a classic "double bubble" sign, of which 32 had duodenal atresia 1
• Other less common causes include duodenal web, congenital midgut volvulus, internal hernia, and obstructing duplication cyst 1

Surgical Management Options

When evaluating the surgical options presented:

1. Duodenoduodenostomy (option c) - This is the gold standard approach for duodenal atresia and stenosis, creating a direct anastomosis between the proximal and distal duodenum 2, 3

2. Division of annular pancreas (option a) - While annular pancreas can cause duodenal obstruction, direct division of the pancreatic tissue is not recommended. When annular pancreas is present, the preferred approach is still duodenoduodenostomy to bypass the obstruction without dividing pancreatic tissue 4

3. Gastroenterostomy (option b) - This is considered an outdated approach. A case report highlights the complications of using gastrojejunostomy for duodenal obstruction, including megaduodenum and dysmotility issues 5

4. Duodenal resection (option d) - This is overly aggressive and unnecessary for duodenal atresia or stenosis, as preservation of duodenal tissue with bypass is preferred 4

Advantages of Duodenoduodenostomy

• Provides direct relief of the obstruction
• Can be performed successfully via both open and laparoscopic approaches 2, 3
• Associated with excellent outcomes - studies show successful laparoscopic duodenoduodenostomy in neonates as small as 1.35 kg 3
• Preserves normal intestinal anatomy and function

Clinical Considerations

Bilious vomiting in a neonate is an ominous sign that requires urgent evaluation and intervention:

• Approximately 20% of neonates with bilious vomiting in the first 72 hours of life may have midgut volvulus, which requires urgent surgery 1
• The combination of bilious vomiting and a double-bubble sign strongly suggests duodenal obstruction that requires surgical correction 1
• Preoperative stabilization with nasogastric decompression, IV fluids, and electrolyte management is essential 6

Potential Complications and Considerations

• Multiple atresias can occur in approximately 15% of patients 1
• Associated anomalies are common in patients with duodenal atresia and should be evaluated 4
• Postoperative care includes gradual advancement of feeds, typically starting around postoperative day 5 in neonates 2

In summary, duodenoduodenostomy is clearly the most appropriate surgical approach for a neonate presenting with bilious vomiting and a double-bubble sign on plain x-ray, as it directly addresses the duodenal obstruction while preserving normal anatomy and function.