Systematic review of laparoscopic repair of duodenal obstruction in neonates

Introduction

Congenital duodenal obstruction (CDO) is a rare congenital abnormality characterized by a blockage or narrowing in the duodenum in the neonate and occurs in approximately 1 in 5,000–10,000 live births (1,2). Causes for CDO include true duodenal atresia, duodenal webs, duodenal stenosis, and annular pancreas, and has a high association with chromosomal abnormalities such as trisomy 21 (3). This condition requires surgical intervention for definitive treatment, and the traditional surgical repair of CDO involves open duodenoduodenostomy (DD) or duodenojejunostomy (DJ) with transverse laparotomy (4-6). In 1977, Kimura et al. introduced the diamond-shaped DD technique to reduce the rate of anastomotic complications by creating a larger stoma site (7). This approach eventually became the gold-standard for treating duodenal atresia and stenosis after demonstrating favorable long-term outcomes in neonates (7,8). Despite this established standard of care, the surgical management of CDO continued to improve and evolve over the past two decades. In 2009, Zuccarello et al. found success with a novel “inverted-diamond-shaped-duodenoduodenostomy” approach, which shortened time to postoperative oral feeding (5). In more recent times, Li et al. reported similar success with shortening time to postoperative feeds in 2021 with a “side-to-side duodenoduodenostomy” technique (9).

In addition to improvements in anastomotic techniques, the repair of CDO has evolved from open to minimally invasive. The first reported cases of laparoscopic CDO repair appeared in the literature as limited case reports or case series in the early 2000s (10). In 2001, Bax et al. reported one of the first successful laparoscopic repair of CDO in a neonate with duodenal atresia (11). These early reports of laparoscopic repair techniques in the following few years demonstrated success and promise, with few rates of anastomotic leaks, and operative times comparable to open repair (12). Despite this early promise, the development of this laparoscopic CDO repair experienced a lag in technological innovation, resulting in high rates of postoperative complications such as anastomotic leaks and conversions to open repair. One group even reported ceasing laparoscopic CDO repair temporarily after finding unacceptably high rates of anastomotic complications during the 2000–2005 time period (13). This lag in the development of laparoscopic CDO persisted until around 2007, when various innovative techniques started to emerge, such as the novel use of nitinol U-clips (Medtronic, Inc., Minneapolis, MN, USA) to reduce the rate of anastomotic leak by limiting trauma to the duodenum (14). Improved surgical techniques and approaches continued to develop during following decade, and this is evidenced by improved trends in laparoscopic outcomes seen in the literature (13,14).

While the laparoscopic repair of CDO has promising benefits such as possible reduced time to enteral feeds and improved cosmesis, its widespread adoption remains the subject of ongoing research and debate over the past two decades. Such debated barriers to performing laparoscopic CDO repair include the possibility of complications such as anastomotic leaks and re-stenosis, as well as limited access to high-resourced facilities and experienced surgeons. However, as surgical techniques and technologies continue to improve, laparoscopic repair of CDO carries the potential to become a safe and efficacious option for neonates. This review seeks to assess the current state of laparoscopic repair of CDO in neonates to evaluate its benefits and risk and provide a perspective for or against its adoption. It further seeks to fulfil a void in current literature of a systematic review that specifically addresses bias by using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool. We present this article in accordance with the PRISMA reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-24-45/rc).

Methods

We conducted an extensive search of all literature between 2000–2024 on duodenal atresia repair in neonates using major medical databases, which included PubMed, EMBASE, and CENTRAL. Search terms included “neonates”, “pediatric”, “duodenal atresia”, “congenital duodenal obstruction”, “laparoscopic repair”, and “minimally-invasive”. Articles were selected if they addressed our aim to examine outcomes of neonates undergoing laparoscopic duodenal atresia repair, as well as to assess the current state of this surgical technique. Inclusion criteria included articles with primary data, which included randomized control trials and retrospective cohort studies. Exclusion criteria included case reports, news articles, systematic reviews, narrative reviews, meta-analyses, and large nationwide database studies.

Each article was then further screened and assessed by two independent reviewers for relevance to our central aim. After article selection, each reviewer independently queried variables and outcomes of interest. Patient demographics included variables such as gestational age, age at operation, weight at birth, weight at time of operation, and presence of associated chromosomal abnormalities. Data on operative techniques included information regarding port placement, anastomosis type, and materials used for anastomosis. Finally, postoperative outcome variables included length of operation, postoperative anastomotic leaks or re-stenosis, time to initial enteral feeds, time to full enteral feeds, and hospital length of stay (LOS). Results of individual studies were depicted in tables and synthesized narratively. Outcome effect measures were maintained in each article’s original reporting format. Thus, aggregate meta-analysis was not synthesized due to variations in outcomes reported, variations in reporting formats, and specific operative techniques evaluated in each article. This was acceptable for the purposes of this study due to our objective of evaluating outcomes across different operative techniques for which no one study captured entirely.

Risk of bias was assessed using the ROBINS-I tool, which includes risk of bias due to confounding factors (e.g., differences in gestational age and comorbid congenital abnormalities between operative techniques), selection of participants into the study, classification of interventions, deviations from intended intervention, missing data, measurement of outcomes, and selection of reported results (15). The reviewers independently assessed each study for bias and resolved disagreements with discussion.

Results

After an exhaustive literature search, 119 articles were identified. Thirty-six articles were selected and examined after title screening, and 23 articles ultimately met our inclusion criteria for this present review according to the PRISMA guidelines (Figure 1). Thirteen studies were excluded for lacking relevance to central aim of evaluating laparoscopic CDO. All 23 articles included in this review were retrospective cohort studies, which reported original primary data on laparoscopic CDO repair performed on neonates. The descriptive information and aims of each study are summarized in Table 1. Of these 23 articles, 11 were comparative studies between open versus laparoscopic CDO repair (16-27). The remainder of these studies primarily looked at laparoscopic CDO repair alone, where 5 were comparative studies between different types of laparoscopic CDO techniques (13,28-31), and 6 were non-comparative studies that shared their institution’s experience with laparoscopic repair of CDO (32-38).

Figure 1 Article selection according to PRISMA 2020 guidelines.

The risk of bias judgements assessed with the ROBINS-I tool are depicted in Table S1. Nine studies were found to have moderate risk of bias, and 14 studies were found to have low risk of bias. Moderate biases tended to be due to differences in gestational age and weight at time of operation that could influence outcomes measured. Overall, risk of bias among selected studies was low due to clear classification and delineation of surgical techniques and outcomes typically reported in patient charts used for retrospective analysis.

Patient selection

All studies in this review examined the laparoscopic repair of CDO in the neonate population and were varied in their patient selection criteria. Baseline demographics of each study are summarized in Table 2, which include gestational age, age at time of surgery, weight, and the presence of congenital syndromes, chromosomal abnormalities, and cardiac defects (Table 2).

Patient age

In the studies that reported gestational age data, the average gestational age of neonates undergoing laparoscopic CDO repair ranged from 35 to 39 weeks (13,17-21,23-25,29,30,33-35,37). These findings agree with previous studies have found that early preterm birth (<34 weeks) was a major factor associated with adverse postoperative outcomes in CDO repair (39). Similarly, in a large database study examining the impact of gestational age on CDO repair outcomes, prematurity was associated with increased risk of postoperative morbidity; however, these authors found that early repair was found to be safe in neonates of at least 33 to 34 weeks of gestation without significant comorbidities preventing surgery (40).

In our review, CDO repair most often occurred within the first week of life (13,17-21,24,25,28,31,32,35-37). Few studies had an age at time of operation that exceeded age 7 days, most notably in the study by Spilde et al. that operated on neonates approximately 40 days after birth and Burgmeier & Schier after around 36 days after birth (16,33). Taken together, this suggests that laparoscopic CDO repair may be suitable for neonates with gestational age greater than 35 weeks and could be performed safely within the first week of life and up to around 1 month after birth. Furthermore, data suggests that adverse outcomes in premature neonates are owed to complications associated with prematurity itself, and that delaying definitive operative repair to allow for further growth may not reduce operative risk (40).

Patient weight

All studies in this review either reported the weight of the neonates at birth or at the time of operation, and this average or median weight typically ranged from 2000 to 3500 grams. On the lower end of patient weight ranges, some studies have reported laparoscopic CDO repairs in patients weighing less than 1,500 grams (19,24,32,33). Deguchi et al. found that very low birth weight (<1,500 grams) was a factor associated with adverse postoperative outcomes in 82 patients who underwent CDO repair at their institution (39).

Despite this, multiple studies note that the repair of CDO in smaller, premature neonates is highly amenable to minimally invasive technique due to the proximal nature of the obstruction. Kay et al. suggest that with the jejunum and ileum remaining decompressed, there is adequate workspace even in neonates weighing less than 1,500 grams from their experience (32,34). This suggests that smaller weight is not a major factor that should preclude neonates from receiving laparoscopic CDO repair.

Chromosomal abnormalities and congenital syndromes

CDO is highly associated with chromosomal abnormalities and congenital syndromes, and specifically, the association between CDO and trisomy 21 is highly studied and documented (3,41). With regards to associated chromosomal abnormalities, multiple studies reported a significant portion of patients who had trisomy 21 (13,16,17,20-25,31-33,35-37). The percentage of patients with trisomy 21 in those studies ranged from 17% to 55%. Parmentier et al. uniquely reported a trisomy 21 incidence of 0% in their cohorts, for which they partially attribute the low rates of postoperative complications (19). However, Singh et al. found that the presence of trisomy 21 was not associated with an increase in morbidity and mortality of neonates with CDO; however, the presence of trisomy 21 carries a higher incidence of associated cardiac defects, and this comorbidity has been found to be associated with poorer outcomes in those undergoing CDO repair (42).

Cardiac abnormalities

CDO is highly associated with concomitant cardiac anomalies. Cardiac abnormalities were reported in multiple studies, and the incidence in these cohorts were variable and ranged from 9% to 63%. Some authors such as Kay et al. have attributed the mortality and morbidity in laparoscopic CDO repairs to the existence of concomitant cardiac disease (32). Sidler et al. included patients with cardiac defects, but specifically excluded patients with large defects, which included large ventricular septal defect, tetralogy of Fallot, and double outlet right ventricle (24). These authors posit that the presence of cardiac anomalies may have contributed to a prolonged anesthetic time in the laparoscopic group, leading to a longer operative time compared to the open group. Similarly, in their findings, Cho et al. acknowledged that their study could have been influenced by selection bias, where patients with a cardiac anomaly and other comorbidities were more frequently treated with open repair (20).

Multiple studies found that laparoscopic CDO repairs were longer than open CDO repairs due to the inherent technical difficulty of the minimally invasive procedure (17,18,20,23,24,26,29). Given the increased risk that cardiac abnormalities pose on this patient population, it is possible that those with a significant cardiac condition would be less suitable to withstand prolonged anesthetic and operative times associated with laparoscopic CDO repair earlier on in an institution’s operating experience.

Concomitant malrotation

Given the high incidence of concomitant malrotation and congenital CDO, Hill et al. found that it was important for the surgeon to intraoperatively evaluate for malrotation in this patient population. In their study, one laparoscopic CDO repair was reoperated on after nine days for a missed malrotation (17). Burgmeier and Schier similarly reported that their laparoscopic CDO repairs that were converted to open in part due to poor visualization associated with malrotation (33). Son & Kien excluded patients with malrotation from their study altogether to eliminate the bias that the presence of malrotation would have on conversion rates (22). These findings suggest that evaluating for concomitant malrotation is critical due to the impact that this has on the conversion rate. It may also suggest that patients with malrotation might be more suitable candidates for open CDO repair with a concomitant Ladd’s band procedure.

Operative technique

Details regarding operative technique were extracted from the selected articles and are summarized in Table 3. Operative data collected included available information on patient positioning, trocar and port placement, incision type for open CDO repair, technique used for anastomosis, and anastomosis type.

Patient positioning

The studies in this review did not consistently report patient positioning in their operative techniques and methods, as patients were typically positioned based on surgeon preference. In the studies that did report specific patient positioning, neonates were often placed supine at the foot of the table, with the surgeon at the foot of the patient, the first assistant at the bottom left side, and the scrub nurse at the bottom right side (21,35,37).

Trocar placement

The laparoscopic repairs performed in this review predominantly involved three port sites, with one port at or near the umbilicus for the laparoscope and two ports in the lateral abdomen for working instruments. Some studies also reported the use of an optional fourth port site if additional retraction of liver was required for better visualization (13,17,32). The minimally invasive nature of laparoscopic CDO repair offers improved cosmesis for patients. Son & Kien agreed that this was a clear advantage of the laparoscopic approach, noting that laparoscopic scars ranged from 3–5 millimeters compared to laparotomy scars that ranged from 5–7 centimeters (22).

Lyu et al. reported success with a “single-port” laparoscopic approach, which involves one port in the umbilicus for the laparoscope, placing the working instrument ports at the 1 o’clock and 9 o’clock positions of the umbilicus to create a “single-site” approach (28). This study found that when comparing this “single-site” approach to a more conventional “three-site” approach with two working ports in the lateral abdomen, they observed similar operative lengths, times to initial and full enteral feeds, and postoperative hospital stay. In addition to being safe and efficacious with a 0% rate of anastomotic complications, the “single-site” approach is a promising technique that offers cosmetic benefits due to the hidden abdominal scar.

Identifying concomitant atresia

The ability to exclude the presence of a distal atresia remains one of the major disadvantages of the laparoscopic approach, and this was a challenge discussed by multiple authors. Spilde et al. suggest that the visualization of the distal intestine with laparoscopic technique is feasible and straightforward. Given the proximal nature of the obstruction, the distal intestine remains collapsed unless there is a distal atresia present. With a distal atresia, the segment between the duodenal obstruction and the intestinal obstruction would be evidently dilated and visible during visual inspection (16). Kay et al. further noted that if time is taken to run the intestine laparoscopically, only a type I atresia (web) can be missed (32). One suggested method for detecting distal atresia involves filling the entire small intestine with saline to confirm its patency and running this bowel laparoscopically (19,21,38). Li et al. report employing this technique using a syringe to puncture the peritoneal cavity and distal duodenum with success (38).

Although a missed distal atresia is a feared complication of laparoscopic CDO repair, St Peter et al. found that the incidence of concomitant jejunoileal atresia is less than 1% in cases of congenital duodenal atresia (41). Given this low incidence, Gracie & Lam offer their technique for distal atresia and report that they prefer to manage small bowel atresia in a separate procedure. They suggest that this approach lessens operative time taken to inspect the intestines laparoscopically and would reduce the rates of postoperative ileus (37). Son & Kien similarly report that they did not consistently check for distal atresia given that their patients were reported to have passed meconium preoperatively (22).

However, there is still a risk for conversion to open repair due to unidentified distal atresia. Jensen et al. reported that they did not routinely evaluate for distal atresia and had two cases converted to open repair, with one being due to atresia in the third portion of the duodenum and the other case being due to concern for additional distal atresia (18). Taken together, despite the low incidence of distal atresia in this patient population, inspection of the distal intestine for atresia appears reasonably feasible with the laparoscopic approach and could be done to reduce the risk of conversion to open repair if there are concerns with distal segment visualization.

Anastomotic technique

Data regarding anastomotic technique are reported in Table 3 and include any information reported on materials used, operative methods, and anastomotic technique employed (Table 3).

Anastomosis type

In both open and laparoscopic repairs, the most common type of anastomosis was a diamond-shaped DD, the anastomotic technique originally popularized by Kimura et al. in the 1970s (7,8). This technique offers the advantage or creating a larger stoma, and Weber et al., demonstrated an association between the diamond-shaped DD and earlier feeding and discharge (43).

Despite this, multiple studies in our review utilized the side-to-side anastomosis technique during laparoscopic CDO repair and found low complication rates (19,24,29). In 2023, Liang et al. directly compared laparoscopic diamond-shaped DD to laparoscopic side-to-side DD and found no significant difference in outcomes (31). Similarly, Khan et al. performed side-to-side on all their laparoscopic CDO repairs and had low rates of complications and relatively quick times to enteral feeds, with only one patient experiencing anastomotic leak (30). These findings suggest that both are reasonable options for anastomosis type in the laparoscopic repair of CDO.

Interrupted vs. running sutures

The use of interrupted versus running sutures is still debated, particularly for the posterior wall of the anastomosis where visualization poses a significant technical challenge. In one study, van der Zee saw a reduction in the rate of anastomotic leaks switching to a continuous running stitch on the posterior wall. They attributed these leaks to the difficulty of estimating the space between interrupted stitches in a less visible portion of the anastomosis (13). Some have suggested that performing a running stitch may increase the risk of postoperative anastomotic stricture or obstruction, but this trend was not significantly evident in our review. Dewberry et al. reported performing interrupted sutures in the anterior wall and a running suture in the posterior wall with one case of stricture, for which they attribute to early institution experience with laparoscopic repair (36). Jensen et al. performed a similar technique and reported one late stricture requiring reoperation (18). Despite this, the rate of postoperative stricture was overall low in these studies, suggesting that performing a running stitch on the posterior wall poses relatively low risk.

Alternatively, Cho et al. reported no anastomotic leaks using interrupted sutures; they described a successful technique which involved alternating Vicryl^® and polydioxanone (PDS), which are differently colored and made visualizing the spaces between the stiches easier (20). Son & Kien, Burgmeier & Schier, MacCormack & Lam, and Oh et al. similarly opted for interrupted sutures and had a 0% leak rate (22,33-35). Together, these findings suggest that interrupted sutures can be used for the posterior wall with success if the spaces between the stitches can be adequately visualized and well-spaced, despite the possibility of increased technical difficulty and increased operative times.

Laparoscopic U-clip vs. miniature stapler vs. handsewn anastomosis

In our review, the reported laparoscopic CDO repair techniques included handsewn anastomoses, as well as anastomoses completed with Nitinol U-clips or miniature stapler. the laparoscopic handsewn approach was the standard of laparoscopic CDO repair when it was first introduced but was associated with unacceptably high rates of leak in the posterior wall of the anastomosis (11). Earlier studies in the 2000s reported novel success using nitinol U-clips to avoid anastomotic leaks and suggested that these clips reduce trauma inflicted on the intestine when compared to handsewn repairs (14,16). Cruz-Centeno et al. similarly reported using nitinol U-clips early in their experience to achieve improved rates of anastomotic leaks (26). However, these U-clips were discontinued from the market and surgeons began investigating the use of Miniature staplers for laparoscopic CDO repair.

Three studies directly compared the use of miniature stapler to handsewn anastomoses for laparoscopic CDO repair. Cruz-Centeno et al. found no differences in outcomes and complication rates when comparing different anastomosis techniques [odds ratio (OR) 1.16, 95% confidence interval (CI): 0.63–2.13; P=0.64] (26). However, both Holler et al. and Khan et al. found advantages for the laparoscopic approach with miniature stapler (29,30). Holler et al. reported their technique of performing laparoscopic CDO repair with miniature stapler and noted that around 50% of these were performed with a DJ rather than a DD. They found that this was likely due to the larger portion of parallel bowel required for an appropriate, tension-free stapled anastomosis (29). These authors favor the laparoscopic stapled approach after finding faster times to enteral feeds (5 vs. 11.9 days; P=0.04) compared to the open approach, as well as comparable anastomotic complications rates when compared to open and laparoscopic handsewn techniques. Furthermore, they found significantly shorter operative times for the laparoscopic stapled group compared to laparoscopic handsewn group (145 vs. 201 minutes; P=0.004).

Similarly, Khan et al. compared laparoscopic repair with miniature stapler to laparoscopic handsewn anastomosis and found no difference in operative length (146 vs. 156 minutes; P=0.69), similar rates of postoperative leaks (0% vs. 20%; P=0.34), and similar times to initial enteral feeds (4.0 vs. 2.2 days; P=0.43). However, they did find a decreased time to full enteral feeds with miniature stapler compared to handsewn (7.6 vs. 11.2 days; P=0.04) and attributed this to the sufficiently wide anastomosis created with this technique (30). Furthermore, despite not reaching significance, they did find a trend towards shorter operative times with the miniature stapler due to the reduction of case complexity, as this avoids the technical difficulty of circular intracorporeal suturing in a small space. Despite the promising benefits of the miniature stapler, these authors still report that this technique was limited in use with small neonates under 1,500 grams in weight due to the size of the instrument itself (30). Taken together, the findings of these studies suggest that miniature staplers may be helpful to reduce case complexity and operative times for institutions earlier in their operative experience with laparoscopic CDO repair, and result in comparable outcomes to repair with laparoscopic handsewn anastomoses. Furthermore, they may provide the benefit of decreasing times to enteral feeds.

Thermal injury

Multiple studies attributed anastomotic breakdown due to thermal injury. Jensen et al. report one case of conversion to open due to thermal injury to the distal duodenum (18). Gfroerer et al. found that one patient, in both laparoscopic and open groups, experienced a localized perforation of the colon likely from thermal lesions with monopolar electrocautery (23). Gracie & Lam report that their most troublesome complication was chylous ascites, which they attribute to a leak caused by excess diathermy; they noted reduced rates of this complication after they were more judicious with their diathermy use in the retroperitoneum (37). The findings from these studies suggest that caution must be taken when using electrocautery with neonatal tissue that is more vulnerable to injury.

Postoperative outcomes

Data regarding postoperative outcomes were extracted from the selected articles and are summarized in Table 4. This data included pertinent outcome variables such as operative length, rates of postoperative anastomotic complications, time to initial enteral feeding, time to full enteral feeding, and hospital LOS. Selected studies vary in patient demographics assigned to laparoscopic and open approaches; practitioners can learn from other institutions’ experiences and evaluate individual patient characteristics to guide clinical decision-making.

Operative length

A disadvantage to laparoscopic CDO repair is prolonged operative time. Most studies in this review that compared the laparoscopic versus open CDO repair approach demonstrated longer operative times for laparoscopic repair. Hill et al. showed a significant yet modest difference of 13 minutes longer for laparoscopic repair (116 vs. 103 minutes, P=0.01), and similarly Cruz-Centeno et al. observed an increase of approximately 20 to 30 minutes in laparoscopic approaches [handsewn (132 minutes), U-clip (126 minutes), and stapled (138 minutes)] compared to open repair (102 minutes; P=0.005) (17,26). However, greater increases of approximately 40 to 60 minutes were found when comparing laparoscopic to open repairs in studies such as Jensen et al. (145 vs. 96 minutes; P=0.001), Cho et al. (168 vs. 109 minutes; P<0.001), and Sidler et al. (218 vs. 179 minutes; P=0.03) (18,20,24). The greatest difference was observed in Gfroerer et al., with an increase in 110 minutes for the laparoscopic group (202 vs. 112 minutes; P<0.001) (23). Several of these studies attribute this increase in time to the inherent technical difficulties that laparoscopic surgery poses, which include limited surgeon expertise and institution experience, as well as challenges with visualization during the surgery.

Some studies also compared different types of laparoscopic repairs to open repairs. Holler et al. compared laparoscopic handsewn (LA-HS), laparoscopic miniature stapler (LA-MS), and open CDO repairs. These authors found that LA-HS was significantly longer than open (201 vs. 94 minutes; P<0.001), but LA-MS was not significantly longer than open (145 vs. 94 minutes; P=0.06). When comparing LA-MS and LA-HS, LA-MS was significantly shorter (145 vs. 201 minutes; P=0.004) (29). These findings suggest that handsewn laparoscopic repairs possess a technical complexity that adds significant operative time to the procedure, and that this could potentially be addressed with the use of the miniature stapler for the anastomosis.

Of note, Kozlov et al. was the only study in our review that demonstrated shorter operative times for laparoscopic CDO repair when compared to open CDO repair. The laparoscopic CDO repair cohort observed a statistically significant, yet clinically modest reduction of 20 minutes in operative time (70 vs. 90 minutes; P<0.001) (25). Taken together, it is likely that laparoscopic CDO repair increases operative complexity and length up to possibly one hour. However, this is possibly an acceptable drawback given the benefits of laparoscopic repair. Furthermore, it is possible that with increased surgeon and institutional experience, these operative times will be reduced further.

Postoperative anastomotic complications

Postoperative anastomotic complications such as leaks, re-stenosis, and obstruction are concerning sequelae that can result from both open and laparoscopic repair of CDO (14). The concern for postoperative anastomotic leak was particularly high in earlier experiences with laparoscopic CDO repair.

However, multiple studies included in our review did not demonstrate any anastomotic leaks in patients undergoing laparoscopic repair (16,17,20-23,28,31-35,38). This is likely due to the improved laparoscopic and intracorporeal suturing techniques that developed throughout the past two decades. In the early 2000s, van der Zee reports their experience with high rates of complications, where they found five anastomotic leaks during the period of 2000–2005. The author attributes these complications to inexperience with the technique early in their institution’s experience with laparoscopic CDO repair (13). The author posits that these leaks occurred at the posterior side of the anastomosis, where it was often difficult to visualize and estimate the distance between sutures. They observed significant improvement in their rates of leaks to 0% after the implementation of a stay suture to stabilize the anastomosis of the posterior wall, and after switching from interrupted sutures to continuous running sutures on the posterior wall.

Alternatively, multiple other studies over the years have demonstrated a 0% anastomotic leak rate using interrupted sutures, as mentioned previously (20,22,33-35). In fact, in 2017, Son & Kien report no anastomotic complications in their laparoscopic repair group compared to their open repair group (0% vs. 6.8%) (22). Kozlov et al. reported a leak rate of 1% in the 69 patients operated on laparoscopically (25). These findings favor the implementation of laparoscopic CDO repair, as the rate of anastomotic leakage appears comparable, if not improved, to that of open repair. Success in minimizing anastomotic complications is likely dependent on experience and improved intracorporeal techniques that have developed over the past few decades.

The rates of stenosis and stricture formation in this review were 16/128 (12.5%). The complication was noted in 6 cases with interrupted suture anastomosis, 7 with running suture anastomosis (posterior and anterior running or posterior running with anterior interrupted), and in three patients who had repair with U-clips. While this can be a difficult problem to treat, it is also sometimes seen after open repair. Long-term monitoring for late complications after laparoscopic CDO repair is necessary.

Time to enteral feeding

One of the primary objectives of CDO repair is tolerance of enteral feedings, and reduced time to feeding is a promising advantage for performing laparoscopic CDO repair. In the studies that compared laparoscopic and open CDO repair, several studies demonstrated that laparoscopic patients had a significantly shorter time to initial enteral feed, with a reduction of approximately 50%. Spilde et al. found a reduction of 6 days favoring the laparoscopic approach (5.4 vs. 11.3 days; P=0.002) (16). Similarly, Son & Kien had a reduction of 3 days (3.9 vs. 7 days; P<0.001), Kozlov et al. had a reduction of 4 days (3 vs. 7 days; P<0.001), and Gfroerer et al. had a reduction of 2 days (1 vs. 3 days; P=0.003) (22,23,25).

This effect is similarly observed when analyzing the time to full enteral feeds in studies that compare laparoscopic to open approaches. Spilde et al. showed a significant reduction of 8 days (9 vs. 16.9 days; P=0.007), Son & Kien had a reduction of 4 days (6.8 vs. 10.6 days; P<0.001), Gfroerer et al. had a reduction of 4 days (8.2 vs. 12.2 days; P=0.02), and Kozlov et al. had a reduction by 3 days (8 vs. 11 days; P<0.001) (16,22,23). Sidler et al. observed a reduction in time to full enteral feeds (7 vs. 11 days; P=0.03), and they report their success to their institution’s policy of commencing enteral feeds early with small intermittent nasogastric feeds around the second postoperative day (24).

Time to enteral feeds was shown to be shorter for different types of laparoscopic repair as well. Holler et al. showed a decreased time to initial enteral feed for both laparoscopic repair with miniature stapler (5 days) and handsewn anastomosis (6.8 days) when compared to open (11.9 days; P=0.10) (29). These results suggest that patients can potentially benefit from the laparoscopic approach due to rapid recovery and early resumption of oral feeding, leading to a swift return to full oral nutrition and discharge.

Of the studies in our review, Parmentier et al. was the only paper that demonstrated significantly slower time to initial enteral feed for the laparoscopic CDO repair group compared to the open CDO repair group (8 vs. 4 days; P=0.009), as well as comparable times to full enteral feed (36 vs. 16.5 days; P=0.14) (19). They attribute this finding to the high rate of parenteral nutrition in their patients, which has been shown by previous studies to be associated with longer time to oral nutrition (44).

The studies that compared different laparoscopic techniques amongst one another also assessed time to initial and full enteral feeds, but these results are not as robust. Khan et al. compared laparoscopic repair with miniature stapler to laparoscopic repair with handsewn anastomosis and did not find a difference in time to initial feed (4 vs. 2 days; P=0.43) but found a significant reduction in time to full enteral feeds (7.6 vs. 11.2 days; P=0.04) (30). However, Holler et al. did not find this advantage for time to initial or full enteral feeds when comparing laparoscopic repair with miniature stapler to laparoscopic repair with handsewn anastomosis (14.5 vs. 21.2 days; P=0.65) (29). Similarly, Cruz-Centeno et al. observed no significant differences in time to initial and full enteral feeds when comparing different laparoscopic techniques to one another [handsewn (11 days) vs. U-clip (11 days) vs. stapled (13 days); P=0.21] (26). These findings suggest that laparoscopic CDO repair has an apparent advantage over open CDO repair with regards to initiation of feeds; however, when comparing different laparoscopic techniques, these results are not as significant.

Hospital LOS

In the studies that compared open to laparoscopic CDO repair, several studies demonstrated that patients who underwent laparoscopic CDO repair experienced shorter hospital lengths of stay. When comparing postoperative LOS between laparoscopic repair and open repair, Spilde et al. showed a reduction of about 7 days (12.9 vs. 20.1 days; P=0.01); Kozlov et al. also showed a reduction of about 7 days (21 vs. 28 days; P=0.001); Cho et al. showed a reduction of 3 days (17 vs. 20; P=0.008); and Son & Kien showed a reduction of about 4 days (8.6 vs. 12.9 days; P<0.001) (16,20,22,25). Holler et al. showed the greatest decrease in hospital LOS for laparoscopic techniques [miniature stapler (35 days), handsewn (30.5 days)], with a reduction of about 20 days when compared to open repair (52.8 days; P=0.04) (29).

Although Hill et al. did not find a difference in postoperative LOS (20 vs. 19 days; P=0.68), they reported significant decreased ventilation times for the laparoscopic cohort compared to the open cohort (2 vs. 4 days; P=0.02) (17). This demonstrates that in addition to the improved cosmesis that minimally invasive techniques offer, laparoscopic CDO has the potential to shorten postoperative recovery time and to reduce the risks associated with prolonged hospital stays.

Conversion to open repair

Laparoscopic repair of CDO poses a risk of conversion to open repair. Of the studies included in our review, three demonstrated relatively high rates of conversion. Jensen et al. reported 7 cases (35%) converted to open, and they attribute this to difficulty with visualization and identifying distal atretic regions (18). Similarly, in the study by Burgmeier & Schier, they attribute their 5 (27%) converted cases converted to lack of experience and poor visualization (33). However, these centers tended to demonstrate higher rates of conversion of to open repair earlier in their institution’s experience with this surgical technique. Cho et al. described experiencing a high conversion rate of 6 cases (23%) in their earlier cases, and that these rates decreased over time with improved experience (20).

These findings suggest that the rates of conversion to open is experience and time-dependent and has the potential to be minimized with improved surgical skill and experience. The study by van der Zee in 2011 directly studied this phenomenon and analyzed the outcomes of neonates undergoing laparoscopic CDO repair from 2000 to 2005 and found the rate of postoperative anastomotic leak and conversion rate to be unacceptably high (13). They found that those undergoing the same procedure from 2008 to 2010 did not experience postoperative complications, and the authors attribute this difference in outcomes to improvement in the surgical technique, specifically through gaining additional experience in intracorporal suturing.

This trend has been evidenced by more recent literature, as seen by studies such as Gracie & Lam in 2023 that demonstrated 0% conversions in 12 laparoscopic cases and by Liang et al. in 2023 that showed 0% conversions in 52 laparoscopic cases (31,37). This trend in the past decade suggests that a steep learning curve exists for this surgical technique; however, when performed by experienced surgeons, laparoscopic CDO repair could prove to be a safe and efficacious procedure.

Discussion

The aim of this study was to examine the current state of laparoscopic CDO repair in neonates and to observe general trends in operative technique. While CDO has traditionally been repaired via open DD or DJ with transverse laparotomy, minimally invasive surgery in this patient population may offer multiple benefits with regards to patient outcomes. This review builds upon the findings of earlier systematic reviews by Zhang et al. and Mentessidou et al. (45,46). First, our study examines the progression of surgical innovations in the repair of CDO in neonates, providing the most current updates in the field. The present analysis also includes more granular insights into specific surgical techniques for both open and laparoscopic approaches. Additionally, we delve deeper into patient selection criteria, noting that the appropriateness of laparoscopic repair may be dependent on factors such as gestational age, weight, and comorbidities. Lastly, we present a detailed perspective on the advantages of laparoscopic repair over open techniques, while also building on our understanding of the current literature with the implementation of the ROBINS-I tool. In agreement with Zhang et al., we find that laparoscopic CDO repair in neonates is safe and has benefits such as faster time to feeds, shorter hospital stays, and lower rates of wound infection compared to open repair (45). Conversely, Mentessidou et al. concluded that with regards to outcomes, laparoscopic repair does not show a clear advantage and is associated with longer operative times (46). Our study alternatively suggests that laparoscopic repair presents distinct benefits despite the extended operative time, while also highlighting how laparoscopic techniques continue to evolve, with promising potential for improving outcomes in this patient population.

Patient selection is important aspect of laparoscopic CDO repair, and this nuanced process needs to be improved and clarified in its current state. Given the confoundingly high rates of comorbid chromosomal abnormalities and congenital heart defects associated with CDO, outcome variables are difficult to study (3). Based on our review, laparoscopic CDO repair appears feasible and safe in all neonates with gestational age greater than 35 weeks and at small weights, even less than 1,500 grams. However, it is unclear whether patients with significant comorbidities, such as concomitant cardiac defects and malrotation, would be appropriate candidates for laparoscopic repair. While trisomy 21 should not necessarily preclude a patient from receiving laparoscopic repair, it is worth noting that the associated cardiac defects may pose a risk to neonates undergoing a prolonged laparoscopic surgery. Furthermore, patients with a concomitant malrotation may experience higher rates of postoperative complications, as well as higher rates of conversion to open repair due to issues regarding visualization. Two studies in our review found relative success by excluding patients with these significant comorbidities altogether, and this is a worthwhile consideration when deciding if a neonate is more suitable for open versus laparoscopic repair (19,24). Although multiple studies have compared laparoscopic and open repair and found benefits with laparoscopic approaches, further studies are still required to better validate appropriate patient selection criteria.

It is worth noting that the demanding surgical skill and training required to perform laparoscopic CDO poses a major barrier to the technique’s widespread adoption in the neonate population. The implementation of the technique requires experienced surgeons and well-resourced centers. Previous literature has found that centers that are under-resourced demonstrate poorer outcomes for neonates undergoing repair of CDO, regardless of operative approach (47). Furthermore, multiple studies in our review cite early inexperience as the cause for their adverse postoperative outcomes (13). Despite this steep learning curve, our review found that laparoscopic CDO repair continues to trend in the right direction. It is promising that laparoscopic repair has been shown to be feasible in small-volume centers (34). Despite fears of postoperative leaks and stenosis, laparoscopic repair has been more frequently performed in recent years with relatively low rates of anastomotic complications and conversion to open repair. Furthermore, our review found that missed distal atresia was not a significantly concerning complication and was feasibly addressed by some authors who routinely inspected the distal intestine laparoscopically. Regardless, because the overall incidence of distal atresia is as low as 1–2%, and the benefits of laparoscopic CDO repair outweigh this potential risk (41).

As laparoscopic and suturing techniques continue to improve, we expect to observe increased utilization of minimally invasive techniques in neonates with CDO. With continued improvement in technique, we believe that the advantages of minimally invasive CDO repair will become more evident. Despite high rates of leaks and conversions to open repair in its early years, the safety and efficacy of laparoscopic CDO repair have improved significantly over the past two decades (13). Given the advancements seen over time, it is likely that laparoscopic repair will become more widely utilized and will improve patient outcomes. Studies comparing outcomes among different laparoscopic techniques have become more common in recent years, reflecting the growing adoption of this innovative technology.

Although our review found that laparoscopic CDO often resulted in longer operating times due to increased case complexity, this was an acceptable downside in exchange for significantly improved times to enteral feed, reduced postoperative stay, and improved cosmesis. With regards to long-term complications, Sidler et al. proposed that laparoscopic CDO repair may also theoretically result in lower rates of postoperative adhesions and small bowel obstructions, but this phenomenon is yet to be studied in this patient population (24,48).

Overall, these retrospective cohort studies are limited by their small sample sizes and retrospective nature. Despite the presence of studies that compare various techniques, the existing literature is limited by small sample sizes, retrospective nature, and lack of randomization, particularly given that the feasibility of randomization is limited due to the rarity of this condition. As the adoption of laparoscopic CDO repair grows, statistical syntheses can be performed with sufficient power to drive recommendations for optimal techniques and approaches. We encourage centers to continue to report and publish their experiences with this relatively new operative technique. Randomized controlled studies will be necessary to further parse out the benefits of laparoscopic CDO repair. Ultimately, laparoscopic CDO repair will continue to become safer in this patient population as this body of literature grows.

Conclusions

Although laparoscopic CDO repair tends to result in increased operative time and case complexity, our review demonstrates that the overall outcomes favor minimally invasive approaches for the neonate population. Laparoscopic approaches offer promising advantages such as reduced time to enteral feeds, postoperative pain, postoperative LOS, risk of postoperative adhesions, and improved overall cosmesis. Furthermore, the laparoscopic repair of CDO in neonates is an approach that has continued to evolve and experience various improvements in the past two decades due to improved surgical technique and experience. With continued development of this technique, the implementation of minimally invasive CDO repair is feasible in centers with experienced pediatric surgeons. Given these potential benefits, centers with adequate expertise and case volume should consider laparoscopic repair in suitable candidates. Case selection should take into consideration the coexisting comorbidities such as cardiac anomalies or malrotation that would increase operative times and conversion rates.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-45/rc

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Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-45/coif). The authors have no conflicts of interest to declare.

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