Treatment of Duodenal Atresia
Duodenal atresia requires surgical correction via duodenoduodenostomy, with the diamond-shaped anastomosis technique offering superior outcomes including earlier feeding initiation and shorter hospitalization compared to alternative approaches. 1
Diagnosis and Preoperative Management
Diagnosis is typically confirmed by plain abdominal radiographs showing the classic "double bubble" sign with absent distal gas, which indicates gastric and proximal duodenal distension. 2
Upper GI series is usually unnecessary when the classic double bubble with no distal gas is present, as fluoroscopy does not provide additional anatomic details that change management. 2
Nasogastric tube decompression should be initiated immediately to prevent aspiration and reduce gastric distension. 3, 4
Parenteral nutrition support is essential as enteral feeding will be delayed postoperatively. 5
Surgical Approach
Operative Technique Selection
Diamond-shaped duodenoduodenostomy (DDD) is the preferred repair technique, demonstrating significantly earlier feeding onset (4.1 days) compared to side-to-side duodenoduodenostomy (8.0 days) or side-to-side duodenojejunostomy (9.6 days). 1
The anastomosis should be performed in a tension-free transverse fashion after complete exposure and removal of any devitalized tissue, using a one-layer technique. 3, 4, 1
Laparoscopic repair is safe and efficacious in experienced hands, offering shorter hospitalization (16.2 days vs 24-28 days for open) and more rapid advancement to full feeding compared to open approach. 6
Intraoperative Considerations
Explore for multiple atresias during initial surgery, as approximately 15% of patients have multiple sites of obstruction that can be identified and addressed during the primary operation. 2
Assess for associated anomalies including annular pancreas (33%), malrotation (28%), and Down syndrome (24%), which commonly occur with duodenal atresia. 5
Gastrostomy tube placement may be considered for postoperative decompression and feeding access, though this is not universally required. 1
Postoperative Management
Maintain nasogastric decompression until bowel function returns, typically allowing feeding initiation within 3-7 days with laparoscopic repair or 4-10 days with open diamond-shaped anastomosis. 6, 1
Advance enteral feeds slowly as postoperative ileus is common and intestinal function may take time to normalize. 7
Total parenteral nutrition should be continued until adequate enteral intake is established. 5
Monitor for complications including anastomotic leak, stricture, or missed second atresia, though these are rare with proper technique. 1
Critical Pitfalls to Avoid
Do not delay surgical intervention once the diagnosis is confirmed, as duodenal atresia represents complete obstruction requiring operative correction. 5, 7
Avoid routine use of complex drainage procedures or pyloric exclusion, as modern evidence supports primary repair with nasogastric decompression alone for superior outcomes. 3, 4
Do not miss associated malrotation or midgut volvulus, which can present similarly but require urgent surgical intervention to prevent bowel ischemia. 2
Expected Outcomes
Operative mortality for duodenal atresia is approximately 4%, with long-term survival rates of 86% when accounting for associated cardiac and chromosomal anomalies. 5
Excellent short- and long-term outcomes are expected for isolated duodenal atresia with appropriate surgical management and postoperative care. 7
Cardiac anomalies represent the major cause of morbidity and mortality rather than the intestinal obstruction itself, emphasizing the importance of comprehensive preoperative evaluation. 5