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Biliary obstruction is a common gastrointestinal disorder with many etiological factors, such as benign and malignant diseases of the biliary tract, pancreas, and liver. Endoscopic ultrasound guided biliary drainage provides a new method for the treatment of biliary obstruction when ERCP cannula fails.

Background and Objectives: Duodenal atresia and stenosis are common causes of intestinal obstruction. Associated anomalies significantly influence early postoperative mortality, while postoperative complications impact long-term survival. Materials and Methods: Over a 13-year period from January 2010 to August 2023, a total of 74 infants and children with congenital duodenal obstruction were treated at "Grigore Alexandrescu" Children's Emergency Hospital and met the inclusion criteria. All patients diagnosed with duodenal obstruction (both instrinsic and extrinsic causes) were included. Analysed data included congenital anomalies, Apgar scores, birth weights, surgical techniques, and complications. Results: The associated anomalies included cardiac ( n = 33), Down syndrome ( n = 13), neurological ( n = 11), pulmonary (n = 7), renal ( n = 4), skeletal ( n = 1), and gastrointestinal and hepatobiliopancreatic anomalies ( n = 25). In total, 12 patients experienced perioperative ventilation problems. Early postoperative complications (within 30 days) occurred in 21 patients, while 6 had late postoperative complications (after 30 days). Among non-surgical complications, we noted ventilation problems, sepsis ( n = 7), and pneumothorax ( n = 1). Surgical complications included adhesive bowel obstruction ( n = 7), incisional hernia ( n = 3), peritonitis ( n = 3), dysfunctional duodenoduodenostomy or duodenojejunostomy ( n = 3), pneumoperitoneum ( n = 5), enteric fistula ( n = 3), and volvulus ( n = 4). Conclusions: Surprisingly, this retrospective study revealed that an Apgar score below 8, along with neurological and pulmonary abnormalities, is associated with postoperative complications. Conversely, other congenital anomalies, low birth weight, and age at admission do not serve as prognostic factors.

Objective: We present an unusual case of a small para-aortic lymphocele causing duodenal stenosis after lymphadenectomy and discuss its treatment., Case Report: Our case involved a 57-year-old woman with endometrial cancer who underwent surgery, including para-aortic lymphadenectomy. On postoperative day 7, projectile vomiting occurred. Computed tomography (CT) revealed a small lymphocele in the dorsal duodenum, causing duodenal stenosis. Transpercutaneous and transduodenal puncture or surgical procedures were difficult because the cyst was too small. Per endoscopic and gastrointestinal series findings on the postoperative day 22, a liquid diet was presumed to be able to pass through the narrow portion. Hence, concentrated liquid food was administered orally; no vomiting occurred. At 2 months postoperatively, CT showed no lymphocele., Conclusion: Conservative treatment involving waiting for spontaneous lymphocele reduction with a concentrated fluid diet may be considered in such cases if fluid passage is confirmed with endoscopy and gastrointestinal series., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

A 66-year-old man presented with repeated vomiting for 5 days. Initial gastroscopy showed gastric retention while computed tomography (CT) revealed a 1.8*1.1 cm, oval-shaped, high-density object in the duodenum. Considering his past medical history of a surgical repair for duodenal ulcer perforation 20 years ago, a diagnosis of foreign body (FB) impaction causing gastric outlet obstruction was established. After gastric lavage, a second gastroscopy was performed. A brownish round FB impacted upon scarring stenoses at the junction of the 1st and 2nd part of duodenum was visualized after advancement of the scope with effort through a deformed pylorus. Attempts to capture the FB using a polypectomy snare failed because the snare loop could not be advanced across the stenotic impaction site to allow adequate opening. A grasper was also ineffective due to the smooth surface of the FB. Then the ERCP stone extraction technique was applied. Directed by the adjustable tip of a sphincterotome which was introduced through the same gastroscope, a guidewire passed with little resistance over the impaction site for an adequate length. Subsequently, an extraction balloon was advanced through the guidewire with slight inflation to avoid injury to the stenotic duodenal wall and fully inflated in the distal lumen. Gradual balloon deflation and withdrawal applied simultaneously achieved successful removal of the BF, which was identified as an apricot pit. The patient resumed his diet of soft food immediately after the procedure without complaint of any discomfort.

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Purpose: Duodenal obstructions are one of the most common causes of upper intestinal obstruction during the neonatal period. Minimally invasive surgical treatment is considered highly complex. We report our experience with 43 patients treated using this method., Methods: We conducted a retrospective study at our institution from January 2013 to May 2023, including patients classified as having upper intestinal obstructions. All patients received preoperative diagnoses based on clinical findings, radiography, and abdominal ultrasound. Laparoscopic surgery was performed on all patients., Results: We included 43 patients diagnosed with duodenal obstruction (DO) in our study after reviewing the medical records at our hospital for cases meeting this diagnosis. The laparoscopic Kimura procedure was performed on 31 patients (72%), while duodenotomy and anastomosis following the Heineke-Mikulicz principle were performed on 9 patients (21%). In the remaining 3 patients (7%), a side-to-side duodeno-duodeno anastomosis was conducted. Annular pancreas was the most common cause of duodenal obstruction in our series, affecting 21 patients (49%). Type I duodenal atresia was observed in 17 patients (40%), while type III atresia was present in 3 patients (7%), and type II atresia in 2 patients (4%). One case required conversion to open surgery due to concomitant jejunoileal atresia. The only reported complication was partial anastomotic dehiscence, which occurred in two patients (4%)., Conclusions: Minimally invasive surgery (MIS) for managing duodenal obstruction (DO) has proven to be both feasible and safe, yielding comparable outcomes to the traditional open approach; its effectiveness can be significantly enhanced through appropriate training. Furthermore, the growing availability of duodenal atresia simulators offers valuable opportunities to refine laparoscopic skills and apply them effectively. Better outcomes and fewer complications are expected with further experience and an increased number of cases., Level of Evidence: IV, Case series with no comparison group., Competing Interests: Conflicts of interest Authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Intestinal malrotation is an uncommon developmental anomaly that can lead to duodenal obstruction and midgut volvulus. The standard correctional operation, Ladd's operation, is traditionally performed using an open approach, but providers are increasingly performing the procedure laparoscopically. However, there remains concern that the reduced adhesive burden associated with laparoscopy could predispose to recurrent volvulus., Methods: We queried our institutional database from 2012 to 2022 for patients <18 years who underwent Ladd's operation for malrotation. We analyzed baseline characteristics and outcomes including post-operative volvulus, adhesive small bowel obstruction (SBO), duodenal obstruction, and overall abdominal re-operation., Results: We identified 226 patients, of whom 90 (40%) underwent a laparoscopic operation. Those undergoing open surgery were younger and had a higher rate of volvulus compared to laparoscopic patients. There were no differences in surgical history or underlying comorbidities. Laparoscopic patients were less likely to develop a post-operative adhesive SBO [1/90 (1%) vs 14/136 (10.0%); OR 9.4 (1.7-176.4), p = 0.036] with no increased rate of volvulus [1/90 (1%) vs 1/136 (0.7%), p = 0.778]. However, there were four laparoscopic patients that required re-operation for a duodenal stricture or kink, which led the overall rate of abdominal re-operation to not be different [7/90 (8%) vs 16/136 (12%); OR 1.6 (0.6-4.8), p = 0.371]. Median follow up was 2.3 years [IQR 1.0-5.0]., Conclusion: Laparoscopic correction of midgut malrotation demonstrates no increased risk of post-operative volvulus and may reduce the rate of adhesive SBO. These benefits must be weighed against the potential increased risk of duodenal stricture or obstruction secondary to an incomplete Ladd's procedure., Level of Evidence: III., Competing Interests: Conflict of interest The authors have no competing interests to declare. No financial support has been provided for this research., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: The authors declare that they have no conflict of interest.

Background: Endoscopic balloon dilation (EBD) is a safe and effective treatment for Crohn's disease (CD)-associated strictures. However, serial EBDs have rarely been reported. This study aimed to evaluate the efficacy and safety of serial EBDs for treating CD-associated duodenal strictures compared with intermittent EBDs., Methods: Patients with CD-associated duodenal strictures who underwent EBD were recruited. The clinical data, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were divided into a serial dilation group and an intermittent dilation group to analyze the differences in safety and efficacy., Results: Forty-five patients with duodenal CD-associated strictures underwent a total of 139 dilations. A total of 23 patients in the serial dilation group underwent 72 dilations, for a median of 3 (range 3 ~ 4) dilations per patient, and 22 patients in the intermittent dilation group underwent 67 dilations, for a median of 3 (range 1 ~ 6) dilations per patient. Technical success was achieved in 97.84% (136/139) of the patients. During the follow-up period, three patients in the intermittent dilation group underwent surgery, and the total clinical efficacy was 93.33% (42/45). No difference in safety or short-term efficacy was noted between the two groups, but serial EBDs exhibited significantly greater clinical efficacy between 6 months and 2 years. No significant difference in recurrence-free survival was observed, but the median longest recurrence-free survival and recurrence-free survival after the last EBD in the serial dilation group were 693 days (range 298 ~ 1381) and 815 days (range 502 ~ 1235), respectively, which were significantly longer than the 415 days (range 35 ~ 1493) and 291 days (range 34 ~ 1493) in the intermittent dilation group (p = 0.013 and p = 0.000, respectively). At the last follow-up, the mean diameter of the duodenal lumen was 1.17 ± 0.07 cm in the serial dilation group, which was greater than the 1.11 ± 0.10 cm in the intermittent dilation group (p = 0.018). We also found that the Simple Endoscopic Score for Crohn's Disease was associated with an increased risk of surgical intervention (HR 2.377, 95% CI 1.125-5.020; p = 0.023) and recurrence at 6 months after the last EBD (HR 0.698, 95% CI 0.511-0.953; p = 0.024), as assessed by univariate analysis., Conclusions: Compared to the intermittent EBDs, serial EBDs for duodenal CD-associated strictures exhibit greater clinical efficacy within two years and could delay stricture recurrence. We suggest that serial EBDs can be a novel option for endoscopic treatment of duodenal CD-associated strictures., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The present report aims to describe the case of a duodenal obstruction ileus in a dairy cow that was caused by a cage magnet. The 4.7-year-old German Fleckvieh cow was hospitalized because of symptoms of intestinal obstruction such as anorexia, noticeable drop in milk yield, reduced defecation, dehydration and positive percussion and swinging auscultation in a circumscribed area cranial of the right flank over the last 2 ribs. Six months as well as 3 days prior to hospitalization the cow had already been treated for signs of hardware disease, which included administration of a cage magnet.After the initial clinical diagnostic procedure on hospital admission, a diagnostic laparotomy in the right paralumbar fossa was performed to identify the cause of the ileus. The cranial part of the duodenum was markedly dilated, and a solid foreign body was found obstructing the intestine immediately aboral to the duodenal sigmoid flexure. This was identified as a cage magnet, which was massaged in retrograde direction into the pyloric antrum and removed via abomasotomy. The cow recovered from surgical intervention and was discharged from the hospital 6 days later.The present report describes an unusual complication of cage magnet administration, which is a standard veterinary procedure and generally considered a safe treatment option in cows with clinical signs of acute traumatic reticuloperitonitis., Competing Interests: The authors declare that the manuscript was written in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Thieme. All rights reserved.)

Background/purpose: Endoscopic stenting at malignant distal duodenum stenosis (MDDS) is challenging because of the duodenal C-loop configuration, the acute angle of the duodenojejunal junction, and the limited length of the endoscope. Few studies have investigated the clinical outcomes of stenting at the distal duodenum. Therefore, this study aimed to investigate the clinical outcomes of treating MDDS with different types of metallic stents., Methods: From January 2012 to December 2020, fifty-six patients with MDDS who underwent duodenal stenting were enrolled for analysis. Thirty-five patients received uncovered self-expandable metallic stents (UC-SEMS), and twenty-one patients received partially covered self-expandable metallic stents (PC-SEMS). All patients were followed up till death or for 18 months. The clinical success rate, stent dysfunction rate, and stent patency were compared between the groups. Multivariate analysis was conducted to identify factors related to stent dysfunction., Results: The clinical success rates were 85.7 % in both the UC-SEMS and PC-SEMS groups. Stent dysfunction rates (UC-SEMS: 34.3 %, PC-SEMS: 38.1 %, p = 0.773) and the average stent patency (UC-SEMS: 117.2 days, PC-SEMS: 100.0 days, p = 0.576) were not statistically different between the groups. Multivariate analysis disclosed the age ≥65 years was significantly related to stent dysfunction (odds ratio: 4.78, p = 0.031)., Conclusion: Both UC-SEMS and PC-SEMS are safe and effective treatment options for MDDS. However, stent dysfunction remains a significant issue to overcome, particularly in the elderly. Further research is needed to explore novel strategies that can improve the effectiveness of stent placement and reduce the risk of stent dysfunction., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest in this work., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Purpose: This study analyzed the efficacy of web excision combined with a pre-membranous incision on the dilated proximal segment for congenital intestinal atresia with type I and stenosis (CIA-I/S)., Patients and Methods: Twenty-six patients underwent surgery for CIA-I/S from January 1990 to June 2022. Patients were categorized into 3 groups according to the surgical procedure: Group A, web excision with pre-membranous incision of the dilated intestine (n = 14); Group B, enteroplasty with a trans-membranous vertical incision (n = 7) and Group C, diamond-shaped anastomosis (n = 5). To minimize the impact of obstruction location on outcomes, we specifically examined 17 cases of duodenal atresia/stenosis: Group D-A, (n = 6); Group D-B, (n = 6) and Group D-C, (n = 5). We retrospectively compared the operative and postoperative parameters among the three groups., Results: No patient experienced anastomotic leakage or obstruction. There were no significant differences in operative duration or blood loss among the 3 Groups. The median time to feeding initiation was 4, 6.5, and 5 days in Groups A, B, and C, respectively (p = 0.04) and was 4, 6.5, and 5 days in Groups D-A, D-B, and D-C, respectively (p = 0.04)., Conclusion: Web excision, when compared to enteroplasty and diamond-shaped anastomosis, showed comparable results in terms of the operative duration and postoperative complications. However, it may allow for an earlier initiation of enteral nutrition., (© 2024. The Author(s).)

Background: Laparoscopic repair of duodenal atresia (LRDA) remains a technically challenging procedure and its benefits ambiguous. To assess the safety and efficacy of LRDA, we performed a systematic review of techniques and material for LRDA and a meta-analysis comparing outcomes with open repair (OR)., Methods: Comprehensive search of EMBASSE, PubMed and Cochrane was performed from 2000 to 2023. Studies comparing LRDA with OR were identified and outcomes extracted included operative time, time to enteral feeds, length of hospitalisation, anastomotic leaks and stricture and total complications. χ 2 was used to assess associations between complications and conversions rates of different LRDA approaches (laparoscopic technique, suturing technique). Comprehensive meta-analysis was used for Meta-analysis., Results: Twelve studies were identified and 1731 patients were enrolled in the study (398 [LRDA] and 1325 [OR]). Total rate of complications and conversion for LRDA was 15.58% and 18.84%, respectively. Complication rates were not significantly affected by operative technique and suturing technique. Conversion rates were not significantly affected operative technique; using a combination of interrupted and running suturing was significantly higher than using running or interrupted (χ 2  = 7.45, p < 0.05). Anastomotic leaks, strictures and total complications were equivocal between LRDA and OR (OR 1.672, 95% CI 0.796-3.514; OR 2.010, 95% CI 0.758-5.333; OR 1.172, 95% CI 0.195-7.03). Operative time was significantly greater for LRDA (SDM 1.035, 95% CI 0.574-1.495, p < 0.001). Time to initial and full enteral feeds and length of hospitalisation were shorter in the LRDA group (SDM - 0.493, 95% CI - 2.166 to 1.752, p = 0.466; SDM - 0.207, 95% CI - 1.807 to 0.822, p = 0.019; SDM - 0.111, 95% CI - 1.101 to 0.880, p = 0.466, respectively)., Conclusions: LRDA showed equivalent complication rates compared to OR with an additional benefit of quicker establishment of feeds. There was no significant difference in complication and conversion rates between laparoscopic techniques. Despite a longer operative time, LRDA provides a safe minimal access approach for neonates after this consistent implementation of the technique in the past decade., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The annular pancreas (AP) is a rare gastrointestinal congenital malformation, in which malrotation of the pancreatic ventral bud in the seventh week of embryonic development manifests in a partial or complete ring of tissue around the second part of the duodenum., Methods: The main online medical databases such as PubMed, ScienceDirect, Wiley online library, Web of Science, and EBSCO discovery service were used to gather all relevant studies on the AP., Results: A total of 12,729,118 patients were analyzed in relation to the prevalence of AP. The pooled prevalence of AP was 0.0045% (95% CI: 0.0021%-0.0077%). The most frequent comorbidity in adults and children was duodenal obstruction, with a pooled prevalence of 24.04% and 52.58%, respectively (95% CI: 6.86%-46.48% and 35.56%-69.31%, respectively). The most frequent operation in adult patients with AP was duodenojejunostomy, with pooled prevalence established at 3.62% (95% CI: 0.00%-10.74%)., Conclusion: The diagnostic complexity of AP is accentuated by its nonspecific clinical symptoms, making accurate identification reliant on imaging studies. Therefore, having a thorough knowledge of the clinical characteristics of the AP and its associated anomalies becomes paramount when faced with this rare congenital condition., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Familial megaduodenum is an extremely rare congenital disease, with few cases described in the literatura, that is caused by chronic duodenal obstruction of functional type. It presents in the form of nonspecific clinical pseudo-obstruction from infancy, which causes a delay in its diagnosis and treatment. Conservative treatments are rarely sufficient in and of themselves to control the disease, making surgery an effective option in selected patients for relieving or avoiding obstruction, as well as improving duodenal emptying and restoring gastrointestinal tract continuity, paying special attention to the duodenal papilla. We present a case treated at the General Surgery and Digestive Apparatus Service of the Hospital of Mérida and a review of the existing literature.

Objective: To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO)., Design: Systematic review with meta-analysis., Patients: Infants with CDO requiring surgical repair., Interventions: TAT feeding following CDO repair versus no TAT feeding., Main Outcome Measures: The main outcome was time to full enteral feeds. Additional outcomes included use of parenteral nutrition (PN), cost and complications from either TAT or central venous catheter. Meta-analyses were undertaken using random-effects models (mean difference (MD) and risk difference (RD)), and risk of bias was assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool., Results: Twelve out of 373 articles screened met the inclusion criteria. All studies were observational and two were prospective. Nine studies, containing 469 infants, were available for meta-analysis; however, four were excluded due to serious or critical risk of bias. TAT feeding was associated with reduced time to full enteral feeds (-3.34; 95% CI -4.48 to -2.20 days), reduced duration of PN (-6.32; 95% CI -7.93 to -4.71 days) and reduction in nutrition cost of £867.36 (95% CI £304.72 to £1430.00). Other outcomes were similar between those with and without a TAT including inpatient length of stay (MD -0.97 (-5.03 to 3.09) days), mortality (RD -0.01 (-0.04 to 0.01)) and requirement for repeat surgery (RD 0.01 (-0.03 to 0.05))., Conclusion: TAT feeding following CDO repair appears beneficial, without increased risk of adverse events; however, certainty of available evidence is low. Earlier enteral feeding and reduced PN use are known to decrease central venous catheter-associated risks while significantly reducing cost of care., Prospero Registration Number: CRD42022328381., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary A great many endoscopists have experience with treating benign strictures, most commonly in the esophagus but in other locations as well. That having been said, most endoscopists do not have much experience with true luminal webs. These webs are, in practice, very rare. This case illustrates a patient with a significant duodenal stricture from a web that was treated with incisional therapy, similar to what is often performed in people with fibrotic refractory benign esophageal strictures. In this case, an insulated ITknife was used to incise the web, with appropriate hemostasis applied as needed. The images show a very striking result at the end of this procedure. It is interesting that the authors chose to use a feeding tube at the end of the procedure, given how good the result looked; I suspect many endoscopists would have simply initiated oral feeding after the procedure and skipped the feeding tube entirely. This case illustrates how an aggressive endoscopist who is willing to be innovative can produce a significant benefit for a patient in need. Douglas G. Adler, MD, FASGE, GIE Editor-in-Chief Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

Introduction:  Coexistent congenital duodenal obstruction and esophageal atresia (EA) is known to have significant morbidity and mortality. Management strategies are not well-defined for this association. The data from the Turkish EA registry is evaluated., Materials and Methods:  A database search was done for the years 2015 to 2022., Results:  Among 857 EA patients, 31 (3.6%) had congenital duodenal obstruction. The mean birth weight was 2,104 (± 457) g with 6 babies weighing less than 1,500 g. Twenty-six (84%) had type C EA. The duodenal obstruction was complete in 15 patients and partial in 16. Other anomalies were detected in 27 (87%) patients. VACTERL-H was present in 15 (48%), anorectal malformation in 10 (32%), a major cardiac malformation in 6 (19%), and trisomy-21 in 3 (10%). Duodenal obstruction diagnosis was delayed in 10 (32%) babies for a median of 7.5 (1-109) days. Diagnosis for esophageal pathologies was delayed in 2. Among 19 babies with a simultaneous diagnosis, 1 died without surgery, 6 underwent triple repair for tracheoesophageal fistula (TEF), EA, and duodenal obstruction, and 3 for TEF and duodenal obstruction in the same session. A staged repair was planned in the remaining 9 patients. In total, 15 (48%) patients received a gastrostomy, the indication was long-gap EA in 8. Twenty-five (77%) patients survived. The cause of mortality was sepsis ( n  = 3) and major cardiac malformations ( n  = 3)., Conclusion:  Congenital duodenal obstruction associated with EA is a complex problem. Delayed diagnosis is common. Management strategies regarding single-stage repairs or gastrostomy insertions vary notably depending on the patient characteristics and institutional preferences., Competing Interests: None declared., (Thieme. All rights reserved.)

We present a case of obstruction in the third portion of the duodenum secondary to a phytobezoar in an adult patient with no surgical history and without a vegan diet. High intestinal obstruction due to a phytobezoar is rarely described in the literature, posing a diagnostic challenge when evaluating potential differentials in the emergency setting. Subsequently, we conduct a review focusing on tomographic findings and the surgical specimen, highlighting key points to consider when addressing such pathologies.

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. Incomplete duodenal obstruction due to SMAS in neonates is rarely reported in the literature. In this case, it is a full-term 2-day-old male with the complaint of recurrent vomiting starting soon after birth. The patient was diagnosed with SMAS and duodenoduodenostomy was performed. Accompanying Meckel's diverticulum was excised., (Copyright: © 2024 Permanyer.)

Gallstone ileus is an uncommon occurrence and accounts for about 0.3-0.5% of complications of cholelithiasis in elderly patients. Bouveret syndrome is an uncommon medical condition resulting from the blockage of the duodenal bulb by a stone, which consequently obstructs the outlet of the stomach. Until now, a comparison of two different presentations of Bouveret syndrome has not been published in the literature due to the rarity of this pathology. The curious simultaneous occurrence of the two cases discussed here made it possible for us to compare the different diagnostic and therapeutic pathways. In fact, both cases differ not only in their presenting symptoms, but also in the management adopted by the same surgical team.

A 67-year-old man presented to our hospital with vomiting. Esophagogastroduodenoscopy revealed duodenal stenosis and atypical epithelium. A tumor in the pancreatic head, about 30mm in size, involving the superior mesenteric artery and a superior mesenteric vein was identified using abdominal contrast computed tomography (CT). Locally advanced pancreatic cancer was diagnosed in the patient through an endoscopic biopsy. Due to the duodenal stenosis complication, duodenal stent placement was conducted. After stent placement, oral intake was resumed, and improvement of the systemic condition led to chemotherapy (modified FOLFIRINOX). After chemotherapy, CT revealed decreased carcinoma progression and vascular invasion. Conversion surgery was improved, and R0 resection was achieved. Our study showed that duodenal stent placement could enhance prognosis;as a result, it was regarded as a good choice for multidisciplinary therapy.

Background: The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair., Methods: Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis., Results: A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach., Conclusion: The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction:  During the last quarter of a century, new surgical techniques in neonates have been introduced, and neonatal intensive care has developed. Few studies have explored the implementation of new techniques and if outcomes in neonates undergoing gastrointestinal surgery have improved in the last decades. Therefore, this study aimed to investigate possible changes in postoperative outcomes and surgical techniques in all neonates operated for congenital duodenal obstruction (CDO) 1995 to 2020 in Norway., Material and Methods:  This is a national multicenter retrospective study of all neonates undergoing surgery for CDO in Norway from 1995 to 2020. Results from three periods (1995-2003, 2004-2012, and 2013-2020) were compared. The study was approved by the local data protection officers (2020/13386) and (2020/15125)., Results:  We included 186 patients: 41 in period 1 (1995-2003), 83 in period 2 (2004-2012), and 62 in period 3 (2013-2020). Seventy (38%) neonates had Down syndrome and 104 (62%) had additional malformations/disorders. Birth weight, gender, frequency of Down syndrome, and other malformations/disorders did not differ between the three periods. We observed an increased rate of prenatal diagnosis throughout the study period ( p  < 0.001). The only change in surgical technique was the increased use of transanastomotic feeding tubes ( p  < 0.001). Length of stay, postoperative complication rate, days with parenteral nutrition, and 30-day mortality rate were stable over time., Conclusion:  Perioperative treatment and postoperative outcomes in neonates with CDO have been surprisingly unchanged during the last quarter of a century. Only an increased rate of prenatal diagnosis and more frequent use of transanastomotic feeding tubes were observed., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The present study aims to explore the clinical application of enhanced recovery after surgery (ERAS) in pediatric patients with congenital upper gastrointestinal obstruction (CUGIO)., Methods: A total of 82 pediatric patients with CUGIO admitted to the neonatal intensive care unit in Kunming Children's Hospital between June 2017 and June 2021 were enrolled in the present study and divided into two groups: the ERAS group (n = 46) and the control group (n = 36). The ERAS management mode was adopted in the ERAS group, and the conventional perioperative management mode was adopted in the control group., Results: In the ERAS group and the control group, the time to the first postoperative bowel movement was 49.2 ± 16.6 h and 58.4 ± 18.8 h, respectively, and the time to the first postoperative feeding was 79 ± 7.1 h and 125.2 ± 8.3 h, respectively. The differences in the above two indicators between the two groups were statistically significant (P < 0.05). In the ERAS group, the days of parenteral nutrition and the length of hospital stay were 14.5 ± 2.3 d and 18.8 ± 6.4 d, respectively. In the control group, 17.6 ± 2.2 d and 23.1 ± 8.1 d, respectively. The differences in these two indicators between the two groups were statistically significant (P < 0.05)., Conclusion: The ERAS management model had a positive effect on early postoperative recovery in pediatric patients with CUGIO., (© 2023. The Author(s).)

Background: The duodenal web is a thin, elongated, web-like structure that is one of the factors contributing to duodenal obstruction. Only 100 cases have been reported in the literature. We present a 2.5-year-old cachectic Afghan child who did not have any overt signs and symptoms of intestinal obstruction, like recurrent vomiting, abdominal distention, and weight loss. The web was discovered near the intersection of the third and fourth portions, which is an uncommon location for the duodenal web. The late presentation of congenital duodenal web with partial obstruction is rare but well-known and has been reported in this case., Case Presentation: A 2.5-year-old cachectic Afghan child who had recurrent vomiting and experienced abdominal distention was brought to Maiwand Teaching Hospital from the Jabelsuraj region of Parwan province. The patient was suffering from unusual signs and symptoms like recurrent vomiting, abdominal distention, weight loss, and constipation. The diagnosis of these anomalies was established by a detailed history, clinical features, and abdominal CT scan. In the computerized tomography scanning (CT-Scan) image reported, there was a web with stenosis and partial obstruction in the distal aspect of the third-to-fourth portion of the duodenum. After preoperative stabilization, the child was taken for surgery. The abdomen was opened by a right upper abdominal transverse incision. After web resection and duodenoplasty, the patient was shifted to the recovery room in satisfactory condition. The child was allowed to feed after 8 days, which he tolerated well., Conclusion: Congenital duodenal web with partial obstruction is typically observed in the second and third years of life. It is suspected in patients with recurrent vomiting, abdominal distention, weight loss, and constipation. Partial obstruction may not have an overt presentation, making it a challenging diagnosis for general practitioners. Abdomen X-ray and CT scan usually confirm the diagnosis, and successful surgical intervention is recommended., (© 2023. The Author(s).)

Duodenum inversum, or inverted duodenum, is a rare congenital disorder resulting in an abnormal position of the third and/or fourth portions of the duodenum. Most patients are asymptomatic, but others can experience pain, nausea, vomiting, peptic ulcer disease, pancreatitis, and even intestinal obstruction. In this case, we report a patient who presented with acute abdominal pain and vomiting. He was diagnosed with duodenal volvulus and obstruction due to duodenum inversum. After failing nonoperative management, the patient was successfully treated with surgical resection., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The combination of duodenal atresia (DA) and esophageal atresia (EA) is very rare. With improvements in prenatal sonography and the use of fetal magnetic resonance imaging (MRI), these malformations can be diagnosed in a more accurate and timely manner; polyhydramnios remains the most common sign despite having a low specificity. The high rate of associated anomalies (in 85% of cases) can also impact neonatal management and increase the morbidity rate; thus, it is of paramount importance to look for every possible associated malformation, such as VACTERL and chromosomic anomalies. The surgical management of this combination of atresias is not well defined and changes according to the patient's clinical status, the type of EA, and the other associated malformations. Management ranges from a primary approach for one of the atresias with delayed correction of the other (56.8%) to a simultaneous repair of both atresias (33.8%) with or without gastrostomy, or total abstention (9.4%). We suggest that a simultaneous approach can be safely performed on patients in good physical condition, with a birth weight over 1500 g, and with no major respiratory distress; this method begins by closing the tracheoesophageal fistula to protect the lung and then repairing the DA. The mortality rate has decreased over the years, dropping from 71% before 1980 to 24% after 2001. In this review, we present the available evidence on these conditions, focusing mostly on the epidemiology, prenatal diagnosis, neonatal management strategies, and outcome, with the aim of determining how the different clinical features and surgical approaches may impact on morbidity and mortality., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Preduodenal portal vein (PDPV) is a rare congenital anomaly in which the portal vein lies anterior to the duodenum rather than its normal posterior position. It is a known rare cause of duodenal obstruction and can be associated with other anomalies such as malrotation with or without jejunal atresia. Presented is an incidentally found PDPV causing partial duodenal obstruction during exploration for the resection of a gastric mass and placement of open gastrostomy tube for feeding. This was managed with duodenoduodenostomy, re-creating normal anatomy with portal.

The utilization of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) in the setting of an obstructed (ingrown) duodenal stent as a bridge to pancreaticoduodenectomy (PD) remains undescribed. Herein, we report a case study of a 51-year-old patient who underwent EUS-GJ using lumen apposing metal stent (LAMS) for an obstructed duodenal stent during neoadjuvant treatment for duodenal adenocarcinoma. The patient ultimately underwent surgical resection by a classic PD 14 weeks after LAMS placement. EUS-GJ using LAMS represents a potential option as a salvage bridge to surgery for duodenal obstruction in the setting of an obstructed duodenal stent., (© 2023. The Author(s).)

Background: The purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO)., Methods: After IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012-2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography., Results: Among 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028-3012] and 37 weeks (IQR 34-38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19-42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030)., Conclusions: In this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families., Level of Evidence: Diagnostic Study, Level III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The most common type of duodenal atresia (DA) (Type I), also known as duodenal web or membrane can present later in infancy or early childhood if the membrane or web is fenestrated. We describe six patients with delayed presentation of DA., Materials and Methods: Retrospective review of hospital records of six patients with delayed presentation of DA due to fenestrated web managed in Paediatric Surgery Department at a tertiary care institute over a period of 2 years (January 2019 to December 2020) was done. The data of these patients were analysed on the basis of age at presentation, clinical presentation, associated anomalies, radiological findings, intra-operative findings, management and postoperative course., Results: The median age at presentation was 6.5 months (range: 1 month to 10 years). There were four males and two females. The most common presentation was emesis seen in all six patients. Two patients had Down syndrome. Associated congenital anomalies were cardiac in one patient, anterior ectopic anus in one patient and malrotation of midgut in one patient. Upper gastrointestinal contrast suggested incomplete duodenal obstruction in all patients. At laparotomy, fenestrated duodenal membrane was observed in all patients - preampullary in three patients and postampullary in three patients. Lateral duodenotomy, web excision and transverse closure was done in all six patients. The postoperative period was uneventful in all patients and mean duration of hospital stay was 9 days., Conclusion: Fenestrated duodenal webs present a diagnostic challenge to the paediatric surgeons because of delayed and variable clinical presentation. A modification of the present classification of DA has been proposed in this study which would help in better reporting of epidemiology and aid in early diagnosis of this congenital anomaly.

Purpose: The usefulness of endoscopic ultrasound (EUS) in pediatric populations has been recently appreciated; however, published studies on mini-probe EUS in the diagnosis of congenital esophageal stenosis (CES) or congenital duodenal stenosis (CDS) in pre-school patients remain scarce. This study aimed to report the utility of mini-probe EUS for the diagnosis of CES or CDS in pre-school patients based on the etiology., Methods: We retrospectively reviewed the medical records of pediatric patients with CES or CDS who underwent mini-probe EUS through the stenotic segments at our hospital between December 2006 and December 2021., Results: Five patients with CES and one with CDS were enrolled. The median age and body weight when EUS was performed were 12.5 months and 8.5 kg, respectively. Hypoechoic lesions were observed on EUS in three patients, which were assessed as cartilage; one patient had no hypoechoic lesion but had a focal thickness of the muscular layer. They were diagnosed with tracheobronchial remnants based on EUS. The full circumferential wall thickness of the esophagus was visualized in one patient with fibromuscular hypertrophy. The histopathological findings confirmed the diagnoses. In the patient with CDS, EUS findings revealed pancreatic parenchyma encircling the stenotic part of the duodenum. The preoperative diagnosis was annular pancreas. The patient underwent duodenoduodenostomy, and intraoperative findings confirmed the diagnosis., Conclusion: Mini-probe EUS can be recommended as a feasible and safe technique for infants and toddlers. It can effectively diagnose CES or CDS based on etiology and can inform treatment strategies for pre-school patients., (© 2023. The Author(s), under exclusive licence to The Japan Society of Ultrasonics in Medicine.)

Congenital diaphragmatic hernia (CDH) is encountered in just under 1 in 6000 live births, while congenital duodenal obstruction is seen once every 8000 live births. These congenital anomalies have only been reported together as part of the VACTERL syndrome and therefore in isolation represent an incredibly rare occurrence. This is a case report of a girl born at 34 weeks gestation who had an antenatal diagnosis of left CDH. Five days following operative repair of this, there was extensive pneumoperitoneum and pneumothorax. Upper gastrointestinal contrast study showed a perforation of the duodenum and at laparotomy, a duodenal web was found in the fourth part of the duodenum with perforation immediately proximal. Following duodenoduodenostomy, the postoperative recovery was good. She achieved full enteral feeds and was discharged home. This case highlights the importance of considering rare associations if postoperative recovery is not as expected to prevent delay in undergoing definitive treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The presence of duodenal atresia related to type IIIb intestinal atresia is a rare association, with few cases reported in the literature, representing a surgical challenge considering that even isolated cases of type IIIb intestinal atresia are a challenge. The objective was to report the successful surgical management of a case of a complex intestinal malformation, characterized by duodenal occlusion secondary to annular pancreas and type IIIb intestinal atresia, with intestinal malrotation by definition and the presence of Meckel's diverticulum., Clinical Case: We present the case report of a newborn sent to the second level of care with a diagnosis of duodenal obstruction not diagnosed prenatally, which resulted in duodenal atresia due to annular pancreas and type IIIb intestinal atresia according to the Grosfeld classification. The presence of duodenal atresia with type IIIb intestinal atresia is an extremely rare condition, even more so associated with annular pancreas. These cases are a challenge considering the short length of the small intestine and its consequent need for total parenteral nutrition for a prolonged period., Conclusions: The surgical management of this complex intestinal malformation resulted in a case with an adequate post-surgical evolution, based on the immediate start of enteral feeding with a short period of need for total parenteral nutrition that finally resulted in a short hospital stay., (© 2023 Revista Médica del Instituto Mexicano del Seguro Social.)

Background: Outcomes of partially covered self-expandable metal stents (SEMS) as an additional stent after recurrent duodenal obstruction (RDO) have not been elucidated. In this study, we compared outcomes of partially covered and uncovered SEMS placement after RDO in patients with malignant duodenal obstruction and explored factors affecting re-recurrent obstruction and overall survival in this population., Methods: We conducted a retrospective study of patients undergoing SEMS placement for RDO at a cancer institute in Japan from July 2014 to June 2021. Clinical variables and outcomes of patients undergoing partially covered and uncovered SEMS placement were compared., Results: Sixty-one patients underwent SEMS placement after RDO, for which the COMVI stent was used in 38 cases and uncovered stents were used in 23 cases. Stent ingrowth was the most common cause of RDO (51.4%). Stent migration only occurred after partially covered stent placement (20% vs. 0%, p = 0.018). Choice of SEMS had no impact on time to re-RDO (median 2.8 vs. 4.1 months, p = 0.776) or overall survival (median 2.6 vs. 2.4 months, p = 0.703). Median overall survival was longer in patients receiving chemotherapy after second stenting (4.6 vs. 1.8 months, p < 0.001) and shorter in those with early RDO, regardless of the SEMS used. Use of the partially covered stent had no impact on survival or time to RDO., Conclusions: While outcomes after partially covered SEMS placement for RDO were not significantly different from uncovered SEMS, migration remains a concern when they are used as a second stent. Chemotherapy after second stenting was associated with longer overall survival but not with longer time to re-RDO., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We report a 48-year-old woman who underwent surgery in early neonatal period for duodenal atresia and developed subsequent diseases of the upper gastrointestinal tract. Symptoms of gastric outlet obstruction, gastrointestinal bleeding and malnutrition developed over the past 5 years. Inflammatory and cicatricial lesions of gastrojejunostomy formed for congenital duodenal obstruction following annular pancreas required reconstructive surgery.

Purpose: To evaluate long-term outcomes of endoscopic double stenting using anti-reflux metal stents (ARMS) for combined malignant biliary and duodenal obstruction., Methods: Consecutive patients with advanced pancreatic cancer who received endoscopic double stenting with self-expandable metal stents (SEMS) for combined malignant biliary and duodenal obstruction at our institution between July 2014 and March 2021 were evaluated. Patients were divided into the ARMS group, endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) group, and covered metal stent-transpapillary (CMS-transpapillary) group. A Duckbill-type metal stent was used in all ARMS cases., Results: Thirty-eight patients were enrolled: ARMS group (n = 16), EUS-HGS group (n = 13), and CMS-transpapillary group (n = 9). Overall survival among three groups were not significantly different. Recurrent biliary obstruction (RBO) rates of the ARMS, EUS-HGS, and CMS-transpapillary groups were 12.5%, 61.5%, and 88.9% (P < .01) and median time to recurrent biliary obstructions (TRBOs) were not reached, 125 days, and 7 days (P < .01). Median TRBOs of ARMS-choledochoduodenostomy and ARMS-transpapillary were not statistically different. Major causes of RBO were stent occlusion and symptomatic stent migration in the ARMS group, hyperplasia in the EUS-HGS group, and non-occlusion cholangitis in the CMS-transpapillary group., Conclusions: Endoscopic double stenting with ARMS might be an option for combined malignant biliary and duodenal obstruction., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: We aimed to assess the evidence on the efficacy and safety of transanastomotic feeding tubes (TAFTs) in neonates with congenital duodenal obstruction (CDO), we conducted a systematic review., Material and Methods: Using the databases EMBASE, PubMed, and Cochrane, we carried out a thorough literature search up to 2022. Studies comparing TAFT + and TAFT - for CDO were included. We applied a random effect model., Results: 505 CDO patients who met the inclusion criteria were selected. The TAFT + group had a shorter time to reach full feeds (weighted mean difference [WMD]: -6.63, 95% confidence interval [CI]: -8.83 - -4.43; p < 0.001) and had significantly less central venous catheter (CVC) insertion (I 2 = 85%) (RR: 0.43, 95% CI: 0.19-1.00; p < 0.05). Fewer patients in the TAFT + group received parenteral nutrition (PN) (I 2 = 78%) (RR: 0.43, 95% CI: 0.20-0.95; p < 0.05). There was no statistically significant difference in terms of the development of sepsis (I 2 = 37%) (risk ratio [RR]: 1.35, 95% CI: 0.52-3.46; p > 0.05). No statistically significant difference was observed in terms of length of stay (I 2 = 82%) (WMD: 2.22, 95% CI: -7.59-12.03; p > 0.05) and mortality (I 2 = 0%) (RR: 0.55, 95% CI: 0.07-4.34; p > 0.05)., Conclusions: The use of the transanastomotic tube resulted in early initiation of full feeding, less CVC insertion, and less need for PN., (Copyright: © 2023 Permanyer.)

Cholelithiasis complicated by cholecystoduodenal fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. Modern possibilities of intraluminal endoscopy (electrohydraulic lithotripsy) made it possible to avoid intra-abdominal access (laparotomy, laparoscopy) and postoperative complications. Finally, rapid rehabilitation was noted.