Management of duodenal atresia associated with situs inversu
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Duodenal atresia in association with situs inversus abdominus is extremely rare. Care should be taken when selecting appropriate surgical methods, and caution should be exercised during the surgery to avoid misdiagnosis and mistreatment.

A l-day-old boy, born weighing 3 kg by spontaneous vaginal delivery at 38 weeks’ gestation to a G3P1 mother whose pregnancy was complicated by diabetes mellitus was referred following an antenatal sonographic diagnosis of polyhydramnios and DA. The child had not passed meconium and had bile-stained vomiting.

An echocardiography revealed patent ductus arteriosus (PDA) and atrial septal defect (ASD). The abdominal sonography confirmed situs inversus with the liver on the left side and the spleen on the right side. Gastroenterography was then performed to evaluate the probable anatomical abnormalities. Dilated duodenal bulb and stomach were seen at 6 minutes, and only a little contrast medium in the colon was seen at 18 minutes. These images suggested the partial obstruction of the proximal duodenum.

After confirming the condition, the stomach and duodenum were decompressed, and electrolyte losses were corrected as much as possible.

Surgical method: the child was placed in supine position under general anesthesia with tracheal intubation. Laparoscopic examination showed that the omentum was gathered under the liver, and the duodenum was adhered to the gallbladder. After their separation, the proximal duodenum was thickened and that the distal duodenum was thinned. The junction between them presented as slightly pale and dented, which should be considered as membranous duodenal stenosis.

In the laparotomy, the liver, gallbladder, spleen, and pancreas were revealed to be situs inversus. Some of the duodenum, jejunum, and ileum were twisted 360° clockwise along the superior mesenteric artery, which presented severe congestion and edema. The gastroesophageal vessels and mesenteric vessels (veins) were highly filled, but mesenteric pulsations still existed. All of the small intestine was moved out of the incision, held in the surgeon's hands and reverted counterclockwise by 360° to the normal state. It was found that the Ladd bands constricted the surface of the duodenum and colon; therefore, a Ladd procedure was performed, and the appendix was also removed. Gastrointestinal continuity was restored by duodenal-duodenal diamond anastomosis.

The infant was ventilated for 3 days postoperatively and received total parenteral nutrition for 1 week. On the postoperative 7th day, re-examination of the upper gastrointestinal series revealed that the contrast echoed well without extravasation. On the postoperative 13th day, he was discharged from the hospital with cure. He remains well 4 years later.

In conclusion, DA in association with SIA is very rare. Although several theories are put forward to clarify this matter, the proper cause of DA is not well defined. Clinical symptoms and examinations can assist diagnosis, the definitive cause should be ascertained by surgical approach. And attention should be paid to the condition of the SIA to prevent unnecessary injuries.

Source: https://journals.lww.com/md-journal/subjects/Pediatrics/Fulltext/2020/07310/Management_of_duodenal_atresia_associated_with.86.aspx
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