Comparison of outcomes between complete and incomplete congenital duodenal obstruction

Table 1 Demographic data for 50 patients with complete or incomplete congenital duodenal obstruction undergoing operative repair

	Complete	Incomplete	P value
	n = 27	n = 23
Gender (male:female), n (%)	12 (44):15 (56)	12 (52):11 (48)	0.78
Gestational age at birth (wk)	36.0 (31.3-42)	38.7 (30.1-40.1)	0.01a
No CHD + GA ≥ 37 wk (wk)	38.6 (38.3-39.0), n = 4	39.3 (37.1-40.1), n = 15	0.34
GA < 37 wks (patients), n (%)	14 (52)	5 (22)	< 0.05a
Age at operation, AO (d)	1.0 (0-7)	21.0 (3-2790)	< 0.01a
No CHD + GA ≥ 37 wk (d)	1.0 (0-7), n = 4	21.0 (3-2790), n = 15	< 0.01a
Weight at operation (kg)	2.54 (1.48-3.84)	3.27 (2.20-13.80)	< 0.01a
No CHD + GA ≥ 37 wk (kg)	3.20 (2.98-3.45), n = 4	3.92 (2.48-12.80), n = 15	0.37
Associated congenital anomalies (patients), n (%)	20 (74)	7 (30)	< 0.01a
Congenital heart disease (patients), n (%)	18 (67)	3 (13)	< 0.01a
Trisomy 21 (patients), n (%)	11 (41)	4 (17)	0.12
Other anomalies (patients), n (%)	10 (37)	6 (26)	0.55
Details	Butterfly vertebrae (1), esophageal atresia (1), hemolytic disease of the newborn (1), hydronephrosis, unilateral (1), bilateral (1), hypothyreosis (5), funnel trachea (1), polydactyly, unilateral (1), Hirschsprung disease (1), atopic eczema (1)	Pes calcaneus (1), biliary duct hypoplasia (1), celiac disease (1), Cornelia de Lange syndrom (1), sleep apnoea (1), ectrodactyly, bilateral (1), hypospadia (1), patent omphalomesenteric duct (1), glutaric aciduria type 1 (1)

^aP < 0.05; No CHD + GA ≥ 37 wk represents only patients born at gestational age 37 wk or later without congenital heart disease. GA: Gestational age; CHD: Congenital heart disease.

Table 2 Prenatal ultrasonographic detection rate and preoperative diagnostics for 50 patients with complete or incomplete congenital duodenal obstruction, and clinical presentations for 26 patients with prenatally unknown complete or incomplete congenital duodenal obstruction undergoing operative repair

	Complete	Incomplete	P value
	n = 27	n = 23
Fetal US screening, n (%)	261 (96)	23 (100)	1
Prenatally suspected by US (yes:no), n (%)	23 (88):3 (12)	1 (4):22 (96)	< 0.01a
Clinical presentation all prenatally unknown CDO	n = 42	n = 22
Vomiting, n (%)	4 (100)	20 (91)	1
Failure to thrive, n (%)		13 (59)
Intolerance of age-appropriate p.o. intake, n (%)		10 (45)
Constipation, n (%)	1 (25)	7 (32)	1
Postprandial discomfort/pain/restlessness, n (%)		5 (23)
ALTE (aspiration, apnea, bradycardia), n (%)		1 (5)
Intolerance to solid food, n (%)		1 (5)
Preoperative diagnostics	n = 27	n = 23
Plain abdominal X-ray, n (%)	27 (100)	1 (4)	< 0.01a
Upper GI contrast study, n (%)	0	23 (100)	< 0.01a
Gastroduodenoscopy, n (%)	0	4 (17)	0.04a

^aP < 0.05;

¹One maternity in the complete group was unsupervised (no prenatal ultrasound screening);

²n = 4 is sum of three prenatally unsuspected patients plus one patient without prenatal ultrasound. US: ultrasound; p.o.: Per oral; ALTE: Acute life-threatening event; GI: Gastrointestinal; CDO: Congenital duodenal obstruction.

Table 3 Pathologic findings of 50 patients with complete or incomplete congenital duodenal obstruction undergoing operative repair

	Complete	Incomplete	P value
	n = 27	n = 23
Atresia type 1-membrane, n (%)	10 (37)
Type 2-fibrous cord, n (%)	1 (4)
Type 3-gap, n (%)	3 (11)
Annular pancreas, n (%)	15 (56)	3 (13)	< 0.01a
additionally to type 3 atresia, n (%)	2 (7)
Web, n (%)		9 (39)
Ladd´s bands, n (%)		11 (48)
Additional intestinal pathologies
Intestinal malrotation, n (%)	16 (59)	19 (83)	0.12
Second distal stenosis, n (%)	0	1 (4)
Meckel´s diverticulum, n (%)	2 (7)	2 (9)	1

^aP < 0.05.

Table 4 Operative variables and surgical procedures for 50 patients with complete or incomplete congenital duodenal obstruction undergoing operative repair

	Complete	Incomplete	P value
	n = 27	n = 23
Operative time (min), n (%)	168 (75)	163 (101)	0.85
Procedure
Duodenoduodenostomy, n (%)	25 (93)	8 (35)	< 0.01a
Excision of membrane/web and duodenoplasty (Mikulicz), n (%)	2 (7)	4 (17)	0.39
Duodenal freeing, n (%)	15 (56)	13 (57)	1
Ladd´s procedure, n (%)	6 (22)	9 (39)	0.23
Additional procedures
Jejunoplasty (Mikulicz) for second distal stenosis	0	1 (4)	0.46
Appendectomy, n (%)	5 (19)	13 (57)	< 0.01a
Resection of Meckel`s diverticulum, n (%)	2 (7)	2 (9%)	1
Laparoscopic approach, n (%)	12 (44)	16 (70)	0.09
Conversion to open approach, n (%)	1 (8)	2 (13)	1

^aP < 0.05.

Table 5 Postoperative outcomes for 50 patients with complete or incomplete congenital duodenal obstruction undergoing operative repair

	Complete	Incomplete	P value
	n = 261	n = 23
Time from OP to initiation of feeds (d)	3.0 (0-12)	1.0 (0-3)	< 0.01a
No CHD + GA ≥ 37 wk (d)	4 (2-12), n = 4	1 (0-3), n = 15	< 0.01a
Time from OP to full feeds (d)	12.0 (5-22)	6.0 (1-13)	< 0.01a
No CHD + GA ≥ 37 wk (d)	10.5 (5-22), n = 4	6 (3-11), n = 15	0.09
Length of postop. hospital stay (d)	25 (7-40)	9 (3-24)	< 0.01a
No CHD + GA ≥ 37 wk (d)	15.5 (7-25), n = 4	8 (3-21), n = 15	0.14
	n = 27	n = 23
Morbidity (Clavien-Dindo grade I-V), n (%)	15 (56)	2 (9)	< 0.01a
No CHD + GA ≥ 37 wk, n (%)	1 (25), n = 4	1 (7), n = 15	0.39
Surgical morbidity, n (%)	7 (26)	1 (4)	0.06
No CHD + GA ≥ 37 wk, n (%)	1 (25), n = 4	0 (0), n = 15	0.21
Nonsurgical morbidity, n (%)	12 (44)	1 (4)	< 0.01a
No CHD + GA ≥ 37 wk, n (%)	0 (0), n = 4	1 (7), n = 15	1
Mortality, n (%)	1 (3.7)	0 (0)	1
Reoperation, n (%)	3 (12)	0	0.24
Comprehensive complication index	8.7 (0.0-100)	0.0 (0.0-33.7)	< 0.01a
No CHD + GA ≥ 37 wk	0 (0-58.4), n = 4	0 (0-8.7), n = 15	0.30
Follow-up (yr)	5.2 (0.4-13.8)	3.9 (0.8-13.1)	0.41

^aP < 0.05.

¹Parameters time from operative to feeds and length of postoperative hospital stay were calculated from n = 26 since one patient in the complete group died during initial in-patient treatment (severe cardiac decompensation); reoperation was defined as a repetition of a surgical operation undertaken due to lack of success of the first attempt over the whole period of observation; reasons for reoperation included (initially missed) Ladd´s bands or anastomotic leakage of the duodenoduodenostomy; other adverse events that needed an operative intervention (i.e., pleural drainage) are found in Table 6. No CHD + GA ≥ 37 wk represents only patients born at gestational age 37 wk or later without congenital heart disease. GA: Gestational age; CHD: Congenital heart disease.

Table 6 Postoperative adverse events graded according to Clavien-Dindo classification for 50 patients with complete or incomplete congenital duodenal obstruction undergoing operative repair

	Clavien-Dindo grade	Postoperative adverse event	Patient No.	Frequency of occurence, n (%)
Complete	I	Icterus prolongatus	5	1 (2)
		Hyperbilirubinemia	11	1 (2)
		Transient trocar hernia	16	1 (2)
	II	Surgical site infection	5	1 (2)
		Central line infection	3, 6, 39	3 (6)
		Enteritis, Dehydration	2	1 (2)
		Gastroesophageal reflux	22, 32	2 (4)
		Pneumonia	27, 32	2 (4)
		Pericardial effusion	27	1 (2)
		Cardiac insufficiency, ACE inhibitor	31	1 (2)
		Subclavian malpuncture, transfusion	38	1 (2)
		Enterocolitis	43	1 (2)
	IIIa	Gastric bleeding	40	1 (2)
	IIIb	Colon perforation	1, 25	2 (4)
		Colostomy closure	1	1 (2)
		Mesocolonic hernia	1	1 (2)
		Missed Ladd´s bands	22, 32	2 (4)
		Hematothorax, pleural drainage	38	1 (2)
		Anastomotic leakage	40	1 (2)
	IVb	Cardiac failure, multiorgan dysfunction	40	1 (2)
	V	Death	40	1 (2)
Incomplete	I	Postoperative vomiting (> 7 d)	46	1 (2)
	IIIb	Diagnostic gastroduodenoscopy	46	1 (2)
	IIIb	Incisional hernia	2	1 (2)