Pediatr Surg Int (2008) 24:711–714 DOI 10.1007/s00383-008-2142-8
ORIGINAL ARTICLE
Transluminal endoscopic electrosurgical incision of fenestrated duodenal membranes Gerardo Blanco-Rodrı´guez Æ Jaime Penchyna-Grub Æ Juan D. Porras-Herna´ndez Æ Adria´n Trujillo-Ponce
Accepted: 3 April 2008 / Published online: 15 April 2008 Ó Springer-Verlag 2008
Abstract Duodenal fenestrated membranes are traditionally treated by side-to-side diamond-shaped duodenoduodenostomy, or duodenotomy and resection. We describe an alternative endoscopic approach for its resolution. A flexible panendoscopy reaching the duodenal membrane was performed. A balloon was inserted to dilate its orifice. Traction was applied to the balloon to differentiate the border of the membrane forming the duodenal wall. After visualizing the ampulla, the membrane was incised using a sphincterotome or needle knife on two sites opposite to the bile duct. From May 2001 to August 2007, ten patients with a fenestrated duodenal membrane underwent transluminal endoscopic electrosurgical incision (TEEI). Mean patient age was 3.4 years (range 1 month to 15 years). The endoscopic procedure lasted from 30 to 60 min. Oral intake began 24 h postsurgery in eight patients and at 48 h postsurgery in two patients. Hospital stay lasted for 2–5 days. After 1 year of follow-up, eight patients were asymptomatic and thriving at present, and one had a double membrane, required a second endoscopy with TEEI, and has experienced occasional vomiting. An additional asymptomatic patient was lost after 3 months of The authors state that the present study has been approved by the Hospital ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. We also state that all the parents of the patients included in this study gave their informed consent prior to the realization of the procedure. G. Blanco-Rodrı´guez (&) J. Penchyna-Grub J. D. Porras-Herna´ndez A. Trujillo-Ponce Departamento de Cirugı´a de To´rax y Endoscopı´a, Hospital Infantil de Me´xico Federico Go´mez, Secretarı´a de Salud, Dr. Ma´rquez 162, Col. Doctores, Deleg. Cuauhte´moc, 06720 Mexico City, DF, Mexico e-mail:
[email protected]
follow-up. TEEI of fenestrated duodenal membranes is a feasible and effective procedure in children. Keywords Duodenal obstruction Duodenal membrane Duodenal atresia Endoscopic treatment Transluminal management
Introduction Fenestrated duodenal membranes have been traditionally treated with duodenotomy and membrane resection or sideto-side diamond-shaped duodenoduodenostomy [1–4]. Anecdotal reports on endoscopic treatment of duodenal membranes have been published, including enlargement of membrane fenestration performed with high-frequency waves or laser ablation [5–9]. We describe an alternative transluminal electrosurgical endoscopic technique for their treatment.
Materials and methods From May 2001 to August 2007, all patients presenting at our Department with a history of vomiting, upper abdominal distention, failure-to-thrive, upper gastrointestinal series with partial duodenal obstruction, and endoscopic documentation of a fenestrated duodenal membrane underwent transluminal endoscopic electrosurgical incision (TEEI). With previous signing of the informed consent by the parents, the procedure was performed as follows: with the patient under general anesthesia, a video-panendoscope (Pentax Ashai Optical Co., Ltd., Japan) 6 to 10 mm in diameter was introduced into the second portion of the duodenum. After the fenestrated membrane was visualized
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(Fig. 1a), a stone extraction balloon (Tri-ex, Wilson Cook Medical, Winston-Salem, NC, USA) was inserted through the orifice. Next, the balloon was insufflated and gently pulled to expose the membrane’s border and differentiate this from the normal duodenal wall (Fig. 1b). Whenever possible, the membrane’s orifice was dilated with a pneumatic balloon (CRE Fixed Wire Balloon Dilator, Boston Scientific, Natik, MA) (Fig. 1c) to introduce a 6-mm panendoscope for visualization of the ampulla (Fig. 1d). A sphincterotome (Autotome RX Cannulating Sphincterotome, Boston Scientific, Natik, MA) or needle knife (RX Needleknife, Boston Scientific, Natik, MA) was used to radially incise the membrane from 1 to 2 cm opposite the ampulla, (Fig. 2a–c).
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opposite side of the bile duct. Fenestration diameter was 2 mm in three, 4 mm in four, and 6 mm in three patients. Incision length was 1 cm in three, 1.5 cm in five, and 2 cm in two patients. The endoscopic procedure had a duration of 30–45 min in six patients and 46–60 min in four. Seven patients required one incision of the membrane to relieve symptoms, two required two incisions, and one patient required three incisions. Oral intake began before 24 h in eight patients and within 24–48 h in two. Length of hospital stay was 2 days in four patients, 4 days in three, and 5 days in three patients. Nine patients completed at least 1 year of follow-up. Eight are at present asymptomatic and thriving, whereas one experiences occasional vomiting. This latter patient had a double duodenal membrane and required two TEEI sessions. One asymptomatic patient was lost after 3 months of follow-up.
Results There were six female and four male patients, with a mean age of 3.4 years (range 1 month to 15 years). Nine presented with vomiting and one with upper gastrointestinal bleeding. Nine of our ten patients had a membrane located proximally to ampulla. In one patient, we found the distal bile duct to drain in the edge of the membrane. In all the patients, the incision of the membrane was made to the Fig. 1 a Visualization of a duodenal membrane with fenestration. b Gentle traction the membrane. c Balloon dilatation of the fenestration. d Visualization of the ampulla
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Discussion Treatment of duodenal membranes has been surgical, either by laparotomy or laparoscopy: side-to-side diamond-shaped duodenoduodenostomy, duodenojejunostomy, or duodenotomy with membrane resection are traditional approaches [1–4]. These procedures and even the contemporary
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Fig. 2 Incision in the membrane and the endoscopy 1 month later. a Incision of the membrane. b Final aspect after incision. c 1 month later
laparoscopic approach [10] may have several complications such as adhesive intestinal obstruction, anastomotic leak, and surgical site infection. In 1999, Ziu-ul-Miraj et al. described fenestrated duodenal membrane opening using only one incision by means of a duodenotomy, observing good results with few complications [11]. We performed this same procedure using an endoscopic approach, obviating the need of opening and suturing the duodenum and the abdominal wall. In our ten patients, this has proven to be a safe and effective procedure. In addition, it required limited endoscopic time for its completion: all our patients’ TEEIs lasted \60 min. The short time required for initiating oral intake was another advantage of this procedure. All our patients were on full oral intake after 48 h of the incision. This contributed to a hospital stay of no more than 5 days in all patients. Patients who undergo traditional surgical treatment require fasting times of three or more days [10], with [5 days of hospital stay. In our group of patients with partial duodenal obstruction and in the hands of our pediatric endoscopic surgeons, TEEI of fenestrated duodenal membranes has been a safe and effective procedure. This experience in therapeutic pediatric endoscopy notwithstanding, TEEI may be a reproducible noninvasive approach
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Pediatr Surg Int (2008) 24:711–714 10. Rothenberg SS (2002) Laparoscopic duodenoduodenostomy for duodenal obstruction in infants and children. J Pediatr Surg 37:1088–1089 11. Ziu-ul-Miraj M, Madden NP, Brereton RJ (1999) Simple incision: a safe and definitive procedure for congenital duodenal diaphragm. J Pediatr Surg 34:1021–1024
