Ruchi Amin, MD, Walker Sarah, MD, Julie Fritz, MD, Alfonso M Martinez, MD, Marjorie J Arca, MD. Children’s Hospital of Wisconsin
INTRODUCTION: Antral and duodenal webs are mucosal structures, varying from fenestrated diaphragms to partial mucosal crescents, located along the enteral wall. Patients present with varying degrees of gastric outlet obstruction manifesting as vomiting, failure to thrive, or respiratory symptoms. The prevalence is unknown, and diagnosis is difficult. Patients often undergo multiple diagnostic tests and prolonged failed medical therapy.
METHODS: We conducted an IRB-approved institutional case review of 16 infants and children with antral and duodenal webs from 4/1/2005 to 4/1/2015.
RESULTS: There were 7 males and 1 female, with an average age of 44 months at diagnosis. Symptoms included vomiting, failure to thrive, abdominal pain, and abdominal distention. Diagnosis was established by a combination of fluoroscopy and esophagogastroduodenoscopy (EGD) in all patients.
In our first four patients, diagnostic EGD was performed several days prior to surgery; laparotomy was then accomplished without endoscopic guidance. Intraoperative localization of the web is challenging as gastric rugae in a non-distended stomach may assume the appearance of an antral web. Subsequently, four patients had laparotomy with on-table intraoperative EGD to identify the web. However, we found that an open abdomen makes upper endoscopy challenging, and can alter the endoscopic appearance of the web. In fact, one patient required operative web re-excision with pyloroplasty for persistent gastric outlet obstruction after web resection and pyloromyotomy. This prompted a thoughtful discussion for transition in our practice to preoperative EGD with endoscopic identification and marking of the web with methylene blue or endoscopic clips immediately before our incision for web excision. We utilized this technique recently and it has facilitated our operative web resection significantly.
Resection of the web entailed mobilization of the duodenal C-loop, a gastrotomy traversing the antrum and pylorus, resection of the web, and reapproximation of the mucosa. If the web is close to the pylorus, Heinecke-Mikulicz pyloroplasty may be required.
One patients (12.5%) underwent web resection only. Two patients (25%) underwent web resection with pyloromyotomy. Five patients (62.5%) underwent web resection with Heinecke Mikulicz pyloroplasty.
Nasogastric decompression is accomplished for three days. After a contrast study demonstrates anastomotic integrity, feeds are initiated. Average length of stay is 7.4 days.
All 8 of our patients had confirmed pathologic diagnosis of antral web.
CONCLUSION: Antral and duodenal webs should be considered in the differential diagnosis for a vomiting child. EGD is necessary for diagnosis and operative localization of the web.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79356
Program Number: P401
Presentation Session: Poster (Non CME)
Presentation Type: Poster