Christopher J. DiMaio, MD, FASGE from the Icahn School of Medicine at Mount Sinai in New York, New York, USA presents this VideoGIE case “Pediatric therapeutic endoscopy: endoscopic management of a congenital duodenal web.”
This video demonstrates a case of successful endoscopic management of a congential duodenal web in an 8-year-old girl who presented with duodenal obstruction.
Congenital duodenal webs are a rare cause of GI dysfunction in infants and children, having been reported to occur in up to 1/40,000 births. They form as a result of incomplete canalization of the duodenal epithelium, sometime between the 4th and 5th weeks of gestation. These webs typically consist of mucosa and submucosa, and roughly half are located proximal to the major papilla. The traditional approach to management has been with surgical intervention, by either excision and duodenoplasty, or with bypass via a duodeno-duodenostomy or duodeno-jejunostomy. In the present case, we demonstrate the use of a needle knife incision technique to successfully treat one such congential web. The patient tolerated the procedure well, had immediate relief of her symptoms, and has had a durable response given that within 6 months her weight improved from the 25th percentile to the 50th percentile, and repeat EGD at 1 year demonstrated complete resolution of the web with a widely patent membranotomy.
Figure 1. A, Duodenal web at the second portion of the duodenum. B, Widely patent membranotomy site 1 year after endoscopic therapy.
It is a nice example of how we can use standard endoscopic accessories and familiar techniques and use them to provide minimally-invasive therapeutic options in conditions which traditionally would have required surgical intervention. Here we used a technique similar to needle-knife papillotomy and were able to avoid having this young child undergo a surgical intervention which has a relatively high rate of long-term complications.
In any procedure, it is essential to understand the anatomic relationships of the organs and structures you are dealing with. Knowledge of appropriate settings of the electrosurgical generator will minimize the risk of serious complications.
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