St Vladimir Children's Hospital, Tushinskaya Children's Hospital, Moscow, Russia
Background: The current trend of therapy for alimentary tract duplication (ATD) is minimally invasive surgery (MIS). The reported conversion rate, however, is considerably high, up to 30%, particular in newborns and infants. We present our experience with the MIS allowing us to successfully manage ATD with the minimal possible conversion rate.
Methods:
Twenty seven MIS procedures carried out in 25 children with various types of ATD in our tertiary referral hospitals during 2007 to 2013 were retrospectively analyzed.
Results:
The patient age ranged between 5 days to 15 years. The group of newborns and infants included 15 patients (60.0%). 16 children (64%) were symptomatic. In the rest the diagnosis was made with the incidental findings. The diagnostic workup involved US, CT, contrast studies and MRI imaging (Fig. 1 - Fig.3).
The anatomic localization of ATD was supradiaphragmatic in 8 cases, infradiaphragmatic in 14, thoracoabdominal in 1, multiple lesions were in 2.
Total MIS were carried out in 22 cases, assisted MIS - in 3 (Table 1).
Table 1.
Total MIS Video-assisted Conversion
MIS
Esophagus 10 0 0
Stomach 5 0 0
Gastric in pancreas 1 0 0
Duodenum 2 0 0
Jejunum 2 1 1
Ileocecal 2 2 0
Thoraco-abdominal 0 0 1
Total 22(81.5%) 3(11.1%) 2(7.4%)
The laparoscopic approach was used in 17 cases for the following lesions: esophageal (n-1), gastric, (n-5), gastric in the pancreas (n-1), duodenal (n-2), jejunal (n-4) and ileocecal (n-4). Thoracoscopic procedures were carried out in 10 cases for esophageal cysts (n-9) and duodenal duplication extending into the thoracic cavity (n-1). The Interval procedures combining both laparo- and thoracoscopic approchers were carried out in 2 cases of multiple lesions.
The conversion was proceeding with in two cases (7.4%) due to encountered technical difficulties: in one - of the complex thoraco-abdominal cyst and another - massive adhesive process in the abdomen after previous open surgery.
The endosurgical technique involved enucleation with/or without suturing of the muscle coat in 22 cases of cystic non-communicating duplication of various localization (Fig. 4), unroofing with mucosectomy of duodenal cyst in 2 (Fig. 5) and resection in 1 (Table 2).
Table 2.
Enucleation Unroofing Resection
Esophagus 10 0 0
Stomach 5 0 0
Gastric in pancreas 0 0 1
Duodenum 0 2 0
Jejunum 3 0 0
Ileocecal 4 0 0
Total 22(88%) 3(8%) 2(4%)
Intraoperative complications such as mucosal perforations occurred in 2 cases (7.4%). The endosurgical repair with suturing was performed in one of them and in another one of the missed duodenal perforation laparotomy was undertaken on the next day. Postoperatevely all patients made uneventful recovery.
Histopathological examination revealed ectopic mucosa in approximately 25%of the cases of ATD (Fig. 6).
The follow up completed in 20 patients showed no evidence of recurrence.
Conclusion: Total or assisted MIS procedures for ATD are efficacious and safe and can be successfully performed in children including newborns and infants. Furthermore, simple enucleation should be considered as the optimal endosurgical technique for non-communicating cystic type ATD.