weekly_question 13/4/2025

[Admin]

A 3-day-old, full-term boy is POD 2 from duodenoduodenostomy for annular pancreas and duodenal atresia. He has a history of truncus arteriosus on preoperative echocardiogram. He has worsening acidemia, requires epinephrine and dopamine, and a distended abdomen. Abdominal x-rays show free air. What is the best next step in management?

a Pulmonary artery banding

b Repair of truncus arteriosus

c Image guided percutaneous drain placement

d Exploration with pyloric exclusion and g-tube placement

e Exploration and revision of duodenoduodenostomy

[Admin]

Correct answer
e Exploration and revision of duodenoduodenostomy

Patients undergoing duodenoduodenostomy for annular pancreas and duodenal obstruction have a low complication rate. Technical complications include anastomotic leak, stricture, injury to the ampulla of Vater, pancreatic injury, missed secondary atresia, and missed “windsock” web. Postoperative morbidity and mortality is associated with the newborn’s medical comorbidities, specifically complex congenital heart disease and prematurity.

This patient has free air and clinical deterioration from an anastomotic leak. Since he is only POD 2 from his repair, he requires re-exploration and, in most cases, revision or redo of the duodenoduodenostomy. If this is not technically feasible, then a duodenojejunostomy should be considered. A pyloric exclusion with g-tube placement should be considered as a last resort. Anything short of exploration such as image guided percutaneous drain placement will not provide adequate source control. Any cardiac procedure to temporize or definitively treat the patient’s truncus arteriosus should be performed after the anastomotic leak is addressed.

[luai]

C

[Abd El wahed]

C

[M Abdelbary]

E

[Ismailmohamed]

C

[Dr Lu]

C

[AbdullahZahi95]

E

[Moustafa Elayyouti]

c

[Admin]

Correct answer
e Exploration and revision of duodenoduodenostomy

Patients undergoing duodenoduodenostomy for annular pancreas and duodenal obstruction have a low complication rate. Technical complications include anastomotic leak, stricture, injury to the ampulla of Vater, pancreatic injury, missed secondary atresia, and missed “windsock” web. Postoperative morbidity and mortality is associated with the newborn’s medical comorbidities, specifically complex congenital heart disease and prematurity.

This patient has free air and clinical deterioration from an anastomotic leak. Since he is only POD 2 from his repair, he requires re-exploration and, in most cases, revision or redo of the duodenoduodenostomy. If this is not technically feasible, then a duodenojejunostomy should be considered. A pyloric exclusion with g-tube placement should be considered as a last resort. Anything short of exploration such as image guided percutaneous drain placement will not provide adequate source control. Any cardiac procedure to temporize or definitively treat the patient’s truncus arteriosus should be performed after the anastomotic leak is addressed.