Abstract
Background: Congenital duodenal obstruction is one of the most common causes of neonatal intestinal obstruction that occurs 1 in 2500–10,000 live births. Owing to various causes, annular pancreas causing it is very rare. We present our 6‑year experience by analysing clinical spectrum, management and outcome in neonates with annular pancreas causing duodenal obstruction at our hospital. Materials and Methods: We have reviewed all available hospital records of admitted neonates with duodenal obstruction from March 2016 to February 2022. Annular pancreas causing duodenal obstruction was sorted out from it and analysed all collected data according to age, gender, time of presentation, clinical presentations, associated anomalies, management, outcomes and follow‑up period of 1 year. We have excluded malrotation of the gut associated with congenital diaphragmatic hernia and abdominal wall defects. Results: A total of 116 neonates with duodenal obstruction were admitted from March 2016 to February 2022. Fourteen cases were annular pancreas. Out of 14 cases of Annular Pancreas causing Duodenal obstruction, 9 cases were Male, 5 cases were Female (M: F =1.8:1), Mean gestational age at presentation was 36 +/‑ 1 week, and 4 neonates were preterm. The mean birth weight was 2124 ± 700 g. Most common presenting symptoms were vomiting in all 14 cases, bilious in 12 and nonbilious in 2 cases, upper abdominal distention in 11 (78.5%), dehydration in 6 (42.8%), hyperbilirubinemia seen in 4 (28.57%) cases. Associated anomalies were found in 5 cases, malrotation of the gut in 3, Down’s syndrome in 2 and congenital heart disease (CHD) along with Down’s syndrome in 1 case. The diagnosis was made with plain abdominal X‑ray with a characteristic double‑bubble sign in all 14 cases, but the diagnosis of annular pancreas was confirmed during laparotomy. Doppler Ultrasonography of abdomen and pelvis detect malrotation of gut in 3 out of 14 cases of Annular Pancreas causing Duodenal obstruction. All cases were managed surgically by open laparotomy with diamond‑shaped duodenoduodenostomy, bypassing the obstructed duodenum by pancreatic tissue without dividing it. In 3 cases with associated malrotation of gut, were corrected with Ladds’ procedure along with duodeno‑duodenostomy. The average post‑operative hospital stay was 12 ± 2 days. Two neonates died (mortality rate was 14%), one due to CHD and the other due to sepsis. All the cases were followed up for 1 year; during follow‑up period, 2 babies were admitted again for bilious vomiting and dehydration. Both were improved with conservative management. Conclusion: Congenital duodenal obstruction is one of the most common anomalies of neonates. Annular pancreas, though rare, is an important cause of duodenal obstruction. Billious vomiting and characteristic double bubble sign in plain X‑ray abdomen was key for its diagnosis, but confirmed during laparotomy. Diamond‑shaped duodenoduodenostomy was the best surgical option. Mortality in neonates with duodenal obstruction caused by annular pancreas depends on associated anomalies and delayed presentation.
Keywords: Annular pancreas, duodenal obstruction, neonates