Compared with open surgery, pediatric laparoscopic surgery has advantages of less pain, smaller scars and quicker recovery. In treating duodenal obstruction, laparoscopic surgery can minimize the incision, facilitate functional recovery, reduce the use of parenteral nutrition and postoperative analgesics, and shorten the period to initial feeding and LOS in the hospital [4, 5, 6]. However, laparoscopic surgery for duodenal obstruction is technically demanding, especially in neonates, which limits its wide spread. The surgical space is small, which increases the difficulty in exposing the duodenum and the risk of postoperative anastomotic stenosis or leakage. The incidence of conversion to open surgery is as high as 20%-35% [6, 7].
Many surgeries have been designed to treat duodenal membrane, including membrane resection, balloon dilatation under endoscopy, duodenal rhomboid anastomosis, gastrojejunostomy, duodenojejunostomy and duodenojejunostomy, Roux-en-Y anastomosis, etc. Among them, membrane resection and duodenal rhomboid anastomosis can achieve ideal outcomes [8]. Either open surgery or laparoscopic membrane resection brings a good prognosis, but the boundary between the membrane and the bowel wall must be distinguished during the surgery. Damage to the muscular layer may lead to postoperative perforation or stenosis. The duodenal papillae lie on the descending duodenum, and may be injured as the membrane is removed. Any damage to the muscular layer or the papillae should be repaired immediately, which increases the difficulty of surgery and the risk of postoperative events. Duodenal rhomboid anastomosis does not only remove the membrane, but can also avoid damage to the duodenal papilla. However, this technique is cumbersome and changes the physiological continuity of the bowel. In conclusion, laparoscopic surgery of duodenal membrane is minimally invasive, but also challenged by complicated procedures, long operative time and high risk of postoperative events.
In our study, a laparoscopic surgery was modified from membrane resection or rhomboid anastomosis, which enables us to incise the membrane, meanwhile protecting the duodenum wall or papillae. Comparison analysis confirmed its high effectiveness and safety. During the operation, the duodenal membrane was incised longitudinally to reach the contralateral intestinal wall, and then the duodenal incision was sutured transversely. A sufficient intestinal lumen was obtained. The membrane lied in the center of the bowel, and a longitudinal incision was made to obtain the patency of the intestinal lumen, which is similar to the longitudinal incision (not complete excision) of the urethral membrane [9, 10]. Currently, sophisticated laparoscopic procedures are needed to perform gastrointestinal reconstruction in the neonates with duodenal membrane [11]. Our modification has eased the performance of laparoscopic surgery for duodenal membrane.
In this study, compared with open surgery, the modified laparoscopic surgery had some advantages, as shown by its easier intraoperative procedures, earlier postoperative feeding, shorter postoperative LOS, and less postoperative complications. The most concerned complications were anastomotic stricture or leak. New technology has reduced the complications of laparoscopic surgeries [12, 13]. The laparoscopic surgeries for duodenal membrane may be accompanied with short-term complications, such as accidental injury to the papillae or pancreas, emptying disorders, wound infection, and long-term complications, such as adhesive intestinal obstruction and malnutrition [14]. Our modified laparoscopic surgery reduced the risk of damage to the duodenal papillae and intestinal wall. Only one case of postoperative anastomosis obstruction was found and cured by conservative treatment. The long-term postoperative outcomes were similar with those of open surgery, indicating that laparoscopic membrane incision plus duodenal longitudinal incision and transverse suture are feasible for duodenal membrane.
The following points should be paid attention to in the laparoscopic surgery for neonatal duodenal membrane: 1. The transitional segment of the duodenum should be incised, and the length of longitudinal incision is about 4 cm; 2. The membrane in the descending part of the duodenum is often located near the opening of the duodenal papilla; thus it is necessary to be alert to potential injury during membrane incision, and the incision should not be directed to the suspicious papillae; 3. If an injury to the muscular layer of duodenal wall is suspected, a continuous suture should be performed; 3. The duodenum should be suspended properly through the abdominal wall to ease explosion and suture when performing duodenum anastomosis; 4. After the completion of anastomosis, normal saline should be injected through the gastric tube to observe the patency of the intestinal tube and exclude other intestinal malformations [15, 16]; 5. Good perioperative management and parenteral nutrition support are necessary. Neonates at different gestational ages may present different levels of intestinal maturity. Some patients need a long period before initial feeding, which might be associated with severe obstruction and maldevelopment of the distal intestine.
This study has some limitations. It was a retrospective analysis, and the sample was not large enough to allow a comparison of outcomes between laparoscopic membrane resection and laparoscopic membrane incision. Longer follow-up and larger-size studies are needed to determine whether obstruction would occur due to scar hyperplasia or membrane adhesion.