Laparoscopic treatment for incomplete annular pancreas in neonates

Laparoscopic treatment for incomplete annular pancreas in neonates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Laparoscopic treatment for incomplete annular pancreas in neonates Bing Li, Bing Chen, Lin Xia This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4226941/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purposes Incomplete annular pancreas refers to the partial encircling of the second part of duodenum by pancreatic tissue anteriorly and posteriorly. The purpose of this manuscript is to report the rare configuration and the laparoscopic management strategy in neonates. Methods The subjects for this study were 15 consecutive neonates with incomplete annular pancreas during January 2013 and September 2023. The distal duodenum was incised longitudinally and the proximal duodenum was incised transversely 1.0 cm away from the anterior ring of pancreatic tissue. The length of both the incisions was approximately 1.5-2.0 cm. Laparoscopic side-to-side duodenoduodenostomy was then carried out. Results Of all the patients, 6 were male and 9 were female. Crocodile jaw sign pancreas was revealed in all the neonates intraoperatively. Five of the neonates were diagnosed with an annular pancreas coexisting congenital intestinal malrotation, and Ladd’s procedures were performed firstly. Laparoscopic procedures were all completed without conversions. The mean operative time is 82.7 ± 17.5 min in the group (range, 50～120 min). The postoperative recovery was uneventful in all the cases. The mean follow-up duration was 39.9 ± 20.9 months (ranged, 6–60 months). There was not any anastomotic leak and stenosis in the series. Conclusions The rarely reported crocodile jaw sign pancreas should be recognized as a distinct type of annular pancreas and need to be given adequate attention clinically. The laparoscopic side-to-side duodenoduodenostomy is a safe and viable treatment option for experienced surgeons. Laparoscopy annular pancreas crocodile jaw side-to-side anastomosis neonate Figures Figure 1 Introduction An annular pancreas is a rare congenital anomaly and is infrequently reported in literatures [ 1 ]. In neonates, it could cause duodenal obstruction and may be associated with other congenital abnormalities such as Down’s syndrome and intestinal malrotation [ 2 ]. Most of the time, an annular pancreas is complete, and duodenal obstruction may present early in life [ 3 ]. Sometimes, an annular pancreas is incomplete, the pancreatic tissue forms two lobes and extend both anterior and posterior to the duodenum with an acute angle just masquerade a jaw adjacent to the duodenum, and this configuration has been described as the crocodile jaw sign pancreas [ 4 – 6 ]. Knowledge of the rare anatomic variant is essential to identify these entities and help differentiate them from other pathologic conditions, thus preventing misdiagnosis and potential unnecessary investigation or more invasive procedures [ 7 ]. The incomplete annular pancreas is less common than complete type and has scarcely been recorded. In my knowledge there were no large sample systematic studies in literatures. In neonates this configuration was revealed occasionally during surgery. The treatment involves bypass procedures to relieve the duodenal obstruction such as laparoscopic duodenoduodenostomy and gastrojejunostomy [ 8 ]. Fifteen neonates with crocodile incomplete annular pancreas were admitted to our institute and laparoscopic side-to-side duodenoduodenostomy was performed for these cases. This study aimed to demonstrate the diagnostic protocol, as well as review the author’s personal experience, and demonstrate the feasibility of the laparoscopic side-to-side duodenoduodenostomy for the rare entity. Patients and methods Fifteen cases with incomplete annular pancreas treated by laparoscopic duodenoduodenostomy in our department during January 2013 and August 2023 were reviewed. The usage of the laparoscopic skills was determined by the senior surgeon Bing Li. The procedures were carried out by the same surgical team. This study was approved by the Ethics Committee of the Huai’an women and children’s hospital (Jiangsu, China). Written informed consents were obtained from all the parents of the infants preoperatively. Data collected included method of diagnosis, clinical presentations, imaging studies, patient age, and weight at surgery, associated anomalies, and operative procedures performed, intraoperative findings, intraoperative complications, operating time, and postoperative course. Surgical technique of laparoscopic skills: All the newborn patients were placed supine on the table, the screen was placed on the side of the head, and a nasogastric tube and urethral catheter were inserted before surgery. The operating surgeon stood on the right side of the operating table, the assistant and the camera man stood on the opposite side. Four trocars were inserted: a 5-mm trocar was located at the center of umbilicus for a 30 0 laparoscope, CO 2 pneumoperitoneum with a pressure of 6–8 mmHg and a flow of 2–2.5 L/minute was established. The second and third 3-mm ports were inserted respectively at the right lower and upper site of the abdomen just lateral to the edge of the rectus abdominis muscle. An extra 3-mm port was at the left upper quadrant to assist during the operation. A percutaneous stay suture introduced just below the xiphoid process was utilized to snare the round ligament and retract the liver to the anterior abdominal wall to achieve adequate exposure. The dilated proximal duodenum was detected with the laparoscopic visualization. After a Kocher maneuver of the duodenum was accomplished, the site of the obstruction was easily observed in the neonates, the anterior lobe of the crocodile jaw sign pancreas partial encircling the second part of duodenum was detected in 10 of the cases(Fig. 1 ). Continued to mobilize the duodenum and then the decompressed duodenum of the distal part was revealed. It is extremely important to make both sides redundant to minimize possible tension on the anastomosis before the duodenum is incised. After full mobilization of the duodenum, the proximal duodenum was incised 1.0 cm away from the annular pancreas and extended downward slight obliquely. The longitudinal incision of the distal duodenum was 1.0 cm away from the ring of the annular pancreas. The length of both the incisions was approximately 1.5-2.0 cm to ensure a large anastomosis. A stay suture was placed at right corner to set up the side-to-side duodenoduodenostomy, and then the back wall and front wall were sewn respectively. The anastomosis was accomplished with both a separate running suture for the posterior and then anterior wall using 5 − 0 PDS sutures, and intracorporal knot tying was used. Patency of the anastomosis and absence of leak were confirmed by the injection of 30–50 ml saline with methylene blue through the nasogastric tube and slight compression of the gastric front wall. In 5 cases, duodenal occlusion due to Ladd’s bands was observed during laparoscopic exploration. The caecum was at the right upper quadrant of the abdomen. The intestine had a collapsed appearance with partial circulatory compromise. After counter o’clock derotation of the intestine and lysing of the Ladd’s bands with the hook diathermia, the duodenum was fully exposed. Then the dilated proximal and decompressed distal segments were identified and a crocodile jaw sign pancreas was apparent at the second part of the duodenum, and laparoscopic side-to-side duodenoduodenostomy was performed afterwards. The distal bowel was examined for all cases to ensure that there were no obvious secondary atresias and other coexisted malformations. One child was diagnosed with Mekel's diverticulum by abdominal exploration, and Mekel's diverticulum wedge resection and intestinal anastomosis were performed through a slightly enlarged umbilical incision. The patients were monitored postoperatively in the surgical intensive care unit. Feeds were initiated when the intestinal function was fully recovered and drainage from the nasogastric tube is less than 5 ml/kg/day. Postoperative contrast studies were not routinely used in all the patients before oral feedings initiation. The number of days until oral feedings were initiated, the length of hospitalization, length of the operation and the duration of follow-up time were tabulated. Results Fifteen symptomatic neonates with crocodile incomplete annular pancreas were identified. The median age at operation was 1.7 ± 0.8 days (range, 1–3 days) and median weight was 2.6 ± 0.5 kg (range, 1.5–3.2 kg). Of all the patients, 6 were male and 9 were female. Ten had been diagnosed duodenal obstruction prenatally (66.7%). All of the patients presented with bilious vomiting when admitted, and plain abdominal films showed the typical double bubble sign. Upper gastrointestinal contrast study was carried out in all the cases, and duodenal obstruction was showed in all the patients. Incomplete annular pancreas was revealed in all the neonates intraoperatively. Five of the neonates were diagnosed with an annular pancreas coexisting congenital intestinal malrotation intraoperatively, Ladd’s procedures were performed firstly. One child was diagnosed with Mekel's diverticulum intraoperatively; Mekel's diverticulum wedge resection and intestinal anastomosis were performed through a slightly enlarged umbilical incision. Other associated diseases included congenital heart disease (n = 6), and proximal jejunal ectopic pancreas (n = 1), but we didn’t take any surgical strategies to deal with the anomalies during operation. The sign of Down’s syndrome was presented in 2 cases before surgery, in whom trisomy 21 was confirmed later by a chromosomal analysis (47, XY་21). Laparoscopic procedures were all completed without conversions, and there were no intraoperative complications encountered. The mean operative time is 82.7 ± 17.5 min in the group (range, 50ཞ120 min). Intraoperative bleeding was minimal, and no blood transfusion was required in all the cases. Time to initiation of oral feeds was at mean 8.1 ± 1.9 d postoperative days (range, 5–12 days). The postoperative recovery was uneventful in all the cases. The patients were discharged at mean12.8 ± 1.0 d postoperative days (range, 9–15 days). The mean follow-up duration was 39.9 ± 20.9 months (ranged, 5–60 months). There was no anastomotic leak and stenosis in this series. No late complications were encountered during the postoperative follow-up period. Discussion Annular pancreas is a rare congenital malformation in which the duodenum is either completely or partially encircled by the pancreatic tissue [ 9 ]. Complete annular pancreas is a well-known entity in clinic. In the vast majority of doctors, the annular pancreas means a complete ring of pancreatic tissue surrounds the duodenum, a circular or a sandwich sign configuration. In complete cases symptoms usually present early in life with duodenal obstruction symptoms. But due to insufficient specialized symptoms and signs and combined congenital anomalies, the precise diagnosis of annular pancreas is usually difficult to make before surgery in neonates. Annular pancreas usually causes clinical symptoms depends on the degree of duodenal obstruction, which is only surgically treated in symptomatic cases [ 10 ]. Most of the cases have been found in children. But with the improvement of clinical diagnostic techniques, such as ERCP, magnetic resonance cholangiopancreatography (MRCP) and CT scan, preoperative diagnosis has improved considerably in adults [ 11 ]. Complete annular pancreas has been estimated 5–15 cases per 100,000 adults according to autopsy reports [ 6 ]. Incomplete annular pancreas displayed a crocodile jaw appearance, pancreatic tissue extending in an anterolateral, or posterolateral direction to the duodenum, indicating a partial pancreas. In contrast to complete cases, incomplete cases can be totally asymptomatic, and sometimes, they can even remain asymptomatic until adulthood [ 6 ]. So, the partial annular pancreas is not widely recognized clinically and may be undetected, especially in patients who do not present with duodenal obstruction. Furthermore, because the incomplete annular pancreas is less common than complete type, the incidence of the disease is still unknown, and is easier to be misdiagnosed, especially in the asymptomatic neonates and with only few cases being reported till date [ 7 ]. Zhou Y, et al reported eleven patients (45.8%) presented a complete ring of pancreatic tissue surrounding duodenum, the other 13 patients (54.2%) had incomplete annular pancreas [ 11 ]. Totally 42 neonates with congenital annular pancreas were encountered in our institute during 10 years and 15 of the cases were partial annular pancreas with a ratio of 35.7%. According to our experience the crocodile jaw sign pancreas is not very rare in the neonates with annular pancreas. But for newborns, due to low weight and the severity of the disease, sometimes the neonates may even need a ventilator to maintain the vitals, CT and MRCP are not convenient as diagnostic methods, and ERCP is almost impossible [ 12 ]. Therefore, the diagnosis of the annular pancreas mostly depends on the intraoperative findings. So it is very important to detect and ascertain the annular pancreas during surgery, especially for the diagnosis of crocodile jaw sign pancreas to avoid misdiagnosis and delay of the treatment [ 13 ]. In our group, incomplete annular pancreas was revealed after the laparoscopic Kocher maneuver of the duodenum. Once the precise diagnosis was determined, laparoscopic side-to-side duodenoduodenostomy was chosen for these cases [ 14 – 15 ]. In 5 of the cases, duodenal occlusion due to Ladd’s bands was detected firstly. After the Ladd’s procedure was accomplished, the duodenum was fully exposed, then the dilated proximal and decompressed distal segments were identified and a crocodile jaw sign pancreas was apparent afterwards. It is very important to avoid the misdiagnosis of annular pancreas when congenital intestinal malrotation is encountered, especially the crocodile jaw sign pancreas. Son et al [ 8 ] reported excellent results with the technique of laparoscopic side-to-side duodenoduodenostomy, without any complication of stenosis or leakage, and believed that the simple anastomotic technique is a good alternative technical option. Liang Z et al [ 16 ] reported both laparoscopic diamond-shaped and side-to-side duodenoduodenostomy showed good clinical results in the treatment of annular pancreas. They suggested the surgical techniques should be selected based on the surgeon’s experience, as well as the anatomy of duodenum. Our team had compared the side-to-side and diamond-shaped duodenoduodenostomy in 2021 and found that side-to-side duodenoduodenostomy was benefit to the recovery of intestinal function postoperatively, with no complications during the mid-term follow-up period. We believed that the technique of laparoscopic side-to-side duodenoduodenostomy is safe and efficacious and can be a viable option for partial annular pancreas in the neonate at experienced center. Conclusion This study aimed to demonstrate the diagnostic protocol of incomplete annular pancreas in neonates, as well as review the author’s personal experience and demonstrate the feasibility of the laparoscopic side-to-side duodenoduodenostomy for this rare entity. Due to low weight and the severity of the disease, CT, MRCP and ERCP are virtually impossible. So the diagnosis depends on the intraoperative findings mostly. It is important to detect and confirm the diagnosis of partial annular pancreas to avoid misdiagnosis and delay of the treatment. The results showed laparoscopic side-to-side duodenoduodenostomy could be performed safely and successfully in the neonates, even if the neonates coexisted with congenital intestinal malrotation. Declarations Acknowledgments The authors thank Dr Steven S. Rothenberg, The Rocky Mountain Hospital for Children for direction of our laparoscopic technique. Authors Contributions Li Bing collected patients’ records, drafted the article, and performed the review of the literature. Chen Wei-bing was involved in patient management and collected data. Xia Shun-lin was involved in the preparation and revision of the article. Disclosure Statement No competing financial interests exist. Funding Source No funding was secured for this study. Financial Disclosure No financial relationships relevant to this article to disclose. Conflict of Interest The authors have no conflicts of interest to disclose. References Gfroerer S, Theilen TM, Fiegel HC, et al. Comparison of outcomes between complete and incomplete congenital duodenal obstruction. World J Gastroenterol 2019; 25:3787-3797. . Jensen AR, Short SS, Anselmo DM, et al. Laparoscopic versus open treatment of congenital duodenal obstruction: multicenter short-term outcomes analysis. J Laparoendosc Adv Surg Tech A. 2013; 23:876-80. Arora A, Mukund A, Thapar S, et al. Crocodile-jaw pancreas. Indian J Gastroenterol. 2012; 31(5):281. Bashir M, Ilyas M, Choh N, et al. Crocodile-jaw sign. Abdom Radiol (NY). 2018; 43(12):3534-3535. Xiang H, Han J, Ridley WE, et al. Crocodile jaw sign: Annular pancreas. J Med Imaging Radiat Oncol. 2018; 62 Suppl 1:69. Mittal S, Jindal G, Mittal A, et al. Partial annular pancreas. Proc (Bayl Univ Med Cent). 2016; 29(4):402-403. doi: 10.1080/08998280.2016.11929487. Katwal S, Oli R, Bhusal A, et al. Partial annular pancreas as an incidental finding in a patient with intermittent bowel obstruction: A case report. Radiol Case Rep. 2023; 18(11):3968-3971. Son TN, Liem NT, Kien HH. Laparoscopic simple oblique duodenoduodenostomy in management of congenital duodenal obstruction in children. J Laparoendosc Adv Surg Tech A. 2015; 25(2):163-6. Ali Almoamin HH, Kadhem SH, Saleh AM. Annular pancreas in neonates; Case series and review of literatures. Afr J Paediatr Surg. 2022; 19(2):97-101. Hill S, Koontz CS, Langness SM, et al. Laparoscopic versus open repair of congenital duodenal obstruction in infants. J Laparoendosc Adv Surg Tech A. 2011; 21(10): 961-3. Zhou Y, Li X. Investigation of annular pancreas through multiple detector spiral CT (MDCT) and MRI. J Appl Clin Med Phys. 2022; 23(1):e13487. Li B, Chen WB, Wang SQ, et al. Laparoscopic diagnosis and treatment of neonates with duodenal obstruction associated with an annular pancreas: report of 11 cases. Surg Today. 2015; 45(1):17-21. Puneet Mittal, Kamini Gupta, Amit Mittal, et al. Imaging findings in incomplete annular pancreas in adults with crocodile jaw appearance: Report of two cases. International Journal of Health & Allied Sciences. 2016; 5(4): 278 Li B, Chen BW, Xia LS. Laparoscopic side-toside duodenoduodenostomy versus diamond-shaped anastomosis for annular pancreas in the neonate. ANZ J. Surg 2021; 91:1504-8. DOI: 10.1111/ans.16959 Oh C, Lee S, Lee SK, et al. Laparoscopic duodenoduodenostomy with parallel anastomosis for duodenal atresia. Surg Endosc. 2017: 31:2406-2410. Liang Z, Lan M, Xu X, et al. Diamond-shaped versus side-to-side anastomotic duodenoduodenostomy in laparoscopic management of annular pancreas in children: a single-center retrospective comparative study. Transl Pediatr. 2023; 12(10):1791-1799. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4226941","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":289189604,"identity":"e965f300-4872-46d9-b58c-985388a59051","order_by":0,"name":"Bing Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACAwYGxgOJDRIMDOyNjQ8+EKmFAaKF53Cz4QyitTA2AEmJ9DZpDmK0mLMffnDg4Q6LPPnIhw3SDAx2croNBLRY9qQZHEg8I1FseDuxwbiAIdnY7AAhhx1IAGppk0jcODuxIXkG0F/bCGo5//wDRMvMgw2HeYjSciMHYst8CcbGZiK1vCkA+SVxA09iM+MMA2L8cj5948OfO+oS57cff/7jQ4WdHEEtCL1glQbEKgcB+QZSVI+CUTAKRsGIAgDycE4iiiZ1WgAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Bing","middleName":"","lastName":"Li","suffix":""},{"id":289189605,"identity":"90a07f62-e246-4cec-8764-6f43c49ccce2","order_by":1,"name":"Bing Chen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Bing","middleName":"","lastName":"Chen","suffix":""},{"id":289189606,"identity":"58ffb1a8-95b4-454f-9ca5-e868754d738f","order_by":2,"name":"Lin Xia","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Xia","suffix":""}],"badges":[],"createdAt":"2024-04-06 10:29:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4226941/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4226941/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54865169,"identity":"c0eeb1d8-6d3d-473e-b290-4fb51bb76de6","added_by":"auto","created_at":"2024-04-17 20:43:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":132895,"visible":true,"origin":"","legend":"\u003cp\u003eThe anterior lobe of the crocodile jaw sign pancreas partial encircling the second part of duodenum.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4226941/v1/328270df0a9f6047b69ca1d7.jpg"},{"id":54866520,"identity":"6c5089c0-244f-4e33-8a15-1e299b26d8b4","added_by":"auto","created_at":"2024-04-17 20:59:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":234040,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4226941/v1/7f27473b-faa7-4afb-9576-c2aa06d24f6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic treatment for incomplete annular pancreas in neonates","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAn annular pancreas is a rare congenital anomaly and is infrequently reported in literatures [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In neonates, it could cause duodenal obstruction and may be associated with other congenital abnormalities such as Down\u0026rsquo;s syndrome and intestinal malrotation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Most of the time, an annular pancreas is complete, and duodenal obstruction may present early in life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSometimes, an annular pancreas is incomplete, the pancreatic tissue forms two lobes and extend both anterior and posterior to the duodenum with an acute angle just masquerade a jaw adjacent to the duodenum, and this configuration has been described as the crocodile jaw sign pancreas [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Knowledge of the rare anatomic variant is essential to identify these entities and help differentiate them from other pathologic conditions, thus preventing misdiagnosis and potential unnecessary investigation or more invasive procedures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe incomplete annular pancreas is less common than complete type and has scarcely been recorded. In my knowledge there were no large sample systematic studies in literatures. In neonates this configuration was revealed occasionally during surgery. The treatment involves bypass procedures to relieve the duodenal obstruction such as laparoscopic duodenoduodenostomy and gastrojejunostomy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Fifteen neonates with crocodile incomplete annular pancreas were admitted to our institute and laparoscopic side-to-side duodenoduodenostomy was performed for these cases. This study aimed to demonstrate the diagnostic protocol, as well as review the author\u0026rsquo;s personal experience, and demonstrate the feasibility of the laparoscopic side-to-side duodenoduodenostomy for the rare entity.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eFifteen cases with incomplete annular pancreas treated by laparoscopic duodenoduodenostomy in our department during January 2013 and August 2023 were reviewed. The usage of the laparoscopic skills was determined by the senior surgeon Bing Li. The procedures were carried out by the same surgical team. This study was approved by the Ethics Committee of the Huai\u0026rsquo;an women and children\u0026rsquo;s hospital (Jiangsu, China). Written informed consents were obtained from all the parents of the infants preoperatively.\u003c/p\u003e \u003cp\u003eData collected included method of diagnosis, clinical presentations, imaging studies, patient age, and weight at surgery, associated anomalies, and operative procedures performed, intraoperative findings, intraoperative complications, operating time, and postoperative course.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique of laparoscopic skills:\u003c/h2\u003e \u003cp\u003eAll the newborn patients were placed supine on the table, the screen was placed on the side of the head, and a nasogastric tube and urethral catheter were inserted before surgery. The operating surgeon stood on the right side of the operating table, the assistant and the camera man stood on the opposite side.\u003c/p\u003e \u003cp\u003eFour trocars were inserted: a 5-mm trocar was located at the center of umbilicus for a 30\u003csup\u003e0\u003c/sup\u003e laparoscope, CO\u003csub\u003e2\u003c/sub\u003e pneumoperitoneum with a pressure of 6\u0026ndash;8 mmHg and a flow of 2\u0026ndash;2.5 L/minute was established. The second and third 3-mm ports were inserted respectively at the right lower and upper site of the abdomen just lateral to the edge of the rectus abdominis muscle. An extra 3-mm port was at the left upper quadrant to assist during the operation. A percutaneous stay suture introduced just below the xiphoid process was utilized to snare the round ligament and retract the liver to the anterior abdominal wall to achieve adequate exposure.\u003c/p\u003e \u003cp\u003eThe dilated proximal duodenum was detected with the laparoscopic visualization. After a Kocher maneuver of the duodenum was accomplished, the site of the obstruction was easily observed in the neonates, the anterior lobe of the crocodile jaw sign pancreas partial encircling the second part of duodenum was detected in 10 of the cases(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Continued to mobilize the duodenum and then the decompressed duodenum of the distal part was revealed. It is extremely important to make both sides redundant to minimize possible tension on the anastomosis before the duodenum is incised.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter full mobilization of the duodenum, the proximal duodenum was incised 1.0 cm away from the annular pancreas and extended downward slight obliquely. The longitudinal incision of the distal duodenum was 1.0 cm away from the ring of the annular pancreas. The length of both the incisions was approximately 1.5-2.0 cm to ensure a large anastomosis.\u003c/p\u003e \u003cp\u003eA stay suture was placed at right corner to set up the side-to-side duodenoduodenostomy, and then the back wall and front wall were sewn respectively. The anastomosis was accomplished with both a separate running suture for the posterior and then anterior wall using 5\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS sutures, and intracorporal knot tying was used. Patency of the anastomosis and absence of leak were confirmed by the injection of 30\u0026ndash;50 ml saline with methylene blue through the nasogastric tube and slight compression of the gastric front wall.\u003c/p\u003e \u003cp\u003eIn 5 cases, duodenal occlusion due to Ladd\u0026rsquo;s bands was observed during laparoscopic exploration. The caecum was at the right upper quadrant of the abdomen. The intestine had a collapsed appearance with partial circulatory compromise. After counter o\u0026rsquo;clock derotation of the intestine and lysing of the Ladd\u0026rsquo;s bands with the hook diathermia, the duodenum was fully exposed. Then the dilated proximal and decompressed distal segments were identified and a crocodile jaw sign pancreas was apparent at the second part of the duodenum, and laparoscopic side-to-side duodenoduodenostomy was performed afterwards.\u003c/p\u003e \u003cp\u003eThe distal bowel was examined for all cases to ensure that there were no obvious secondary atresias and other coexisted malformations. One child was diagnosed with Mekel's diverticulum by abdominal exploration, and Mekel's diverticulum wedge resection and intestinal anastomosis were performed through a slightly enlarged umbilical incision.\u003c/p\u003e \u003cp\u003eThe patients were monitored postoperatively in the surgical intensive care unit. Feeds were initiated when the intestinal function was fully recovered and drainage from the nasogastric tube is less than 5 ml/kg/day. Postoperative contrast studies were not routinely used in all the patients before oral feedings initiation. The number of days until oral feedings were initiated, the length of hospitalization, length of the operation and the duration of follow-up time were tabulated.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFifteen symptomatic neonates with crocodile incomplete annular pancreas were identified. The median age at operation was 1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 days (range, 1\u0026ndash;3 days) and median weight was 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 kg (range, 1.5\u0026ndash;3.2 kg). Of all the patients, 6 were male and 9 were female. Ten had been diagnosed duodenal obstruction prenatally (66.7%). All of the patients presented with bilious vomiting when admitted, and plain abdominal films showed the typical double bubble sign. Upper gastrointestinal contrast study was carried out in all the cases, and duodenal obstruction was showed in all the patients. Incomplete annular pancreas was revealed in all the neonates intraoperatively.\u003c/p\u003e \u003cp\u003eFive of the neonates were diagnosed with an annular pancreas coexisting congenital intestinal malrotation intraoperatively, Ladd\u0026rsquo;s procedures were performed firstly. One child was diagnosed with Mekel's diverticulum intraoperatively; Mekel's diverticulum wedge resection and intestinal anastomosis were performed through a slightly enlarged umbilical incision. Other associated diseases included congenital heart disease (n\u0026thinsp;=\u0026thinsp;6), and proximal jejunal ectopic pancreas (n\u0026thinsp;=\u0026thinsp;1), but we didn\u0026rsquo;t take any surgical strategies to deal with the anomalies during operation. The sign of Down\u0026rsquo;s syndrome was presented in 2 cases before surgery, in whom trisomy 21 was confirmed later by a chromosomal analysis (47, XY་21).\u003c/p\u003e \u003cp\u003eLaparoscopic procedures were all completed without conversions, and there were no intraoperative complications encountered. The mean operative time is 82.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5 min in the group (range, 50ཞ120 min). Intraoperative bleeding was minimal, and no blood transfusion was required in all the cases. Time to initiation of oral feeds was at mean 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 d postoperative days (range, 5\u0026ndash;12 days). The postoperative recovery was uneventful in all the cases. The patients were discharged at mean12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 d postoperative days (range, 9\u0026ndash;15 days). The mean follow-up duration was 39.9\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9 months (ranged, 5\u0026ndash;60 months). There was no anastomotic leak and stenosis in this series. No late complications were encountered during the postoperative follow-up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAnnular pancreas is a rare congenital malformation in which the duodenum is either completely or partially encircled by the pancreatic tissue [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Complete annular pancreas is a well-known entity in clinic. In the vast majority of doctors, the annular pancreas means a complete ring of pancreatic tissue surrounds the duodenum, a circular or a sandwich sign configuration. In complete cases symptoms usually present early in life with duodenal obstruction symptoms. But due to insufficient specialized symptoms and signs and combined congenital anomalies, the precise diagnosis of annular pancreas is usually difficult to make before surgery in neonates. Annular pancreas usually causes clinical symptoms depends on the degree of duodenal obstruction, which is only surgically treated in symptomatic cases [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost of the cases have been found in children. But with the improvement of clinical diagnostic techniques, such as ERCP, magnetic resonance cholangiopancreatography (MRCP) and CT scan, preoperative diagnosis has improved considerably in adults [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Complete annular pancreas has been estimated 5–15 cases per 100,000 adults according to autopsy reports [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIncomplete annular pancreas displayed a crocodile jaw appearance, pancreatic tissue extending in an anterolateral, or posterolateral direction to the duodenum, indicating a partial pancreas. In contrast to complete cases, incomplete cases can be totally asymptomatic, and sometimes, they can even remain asymptomatic until adulthood [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. So, the partial annular pancreas is not widely recognized clinically and may be undetected, especially in patients who do not present with duodenal obstruction. Furthermore, because the incomplete annular pancreas is less common than complete type, the incidence of the disease is still unknown, and is easier to be misdiagnosed, especially in the asymptomatic neonates and with only few cases being reported till date [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eZhou Y, et al reported eleven patients (45.8%) presented a complete ring of pancreatic tissue surrounding duodenum, the other 13 patients (54.2%) had incomplete annular pancreas [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Totally 42 neonates with congenital annular pancreas were encountered in our institute during 10 years and 15 of the cases were partial annular pancreas with a ratio of 35.7%. According to our experience the crocodile jaw sign pancreas is not very rare in the neonates with annular pancreas.\u003c/p\u003e \u003cp\u003eBut for newborns, due to low weight and the severity of the disease, sometimes the neonates may even need a ventilator to maintain the vitals, CT and MRCP are not convenient as diagnostic methods, and ERCP is almost impossible [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the diagnosis of the annular pancreas mostly depends on the intraoperative findings. So it is very important to detect and ascertain the annular pancreas during surgery, especially for the diagnosis of crocodile jaw sign pancreas to avoid misdiagnosis and delay of the treatment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our group, incomplete annular pancreas was revealed after the laparoscopic Kocher maneuver of the duodenum. Once the precise diagnosis was determined, laparoscopic side-to-side duodenoduodenostomy was chosen for these cases [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In 5 of the cases, duodenal occlusion due to Ladd’s bands was detected firstly. After the Ladd’s procedure was accomplished, the duodenum was fully exposed, then the dilated proximal and decompressed distal segments were identified and a crocodile jaw sign pancreas was apparent afterwards. It is very important to avoid the misdiagnosis of annular pancreas when congenital intestinal malrotation is encountered, especially the crocodile jaw sign pancreas.\u003c/p\u003e \u003cp\u003eSon et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported excellent results with the technique of laparoscopic side-to-side duodenoduodenostomy, without any complication of stenosis or leakage, and believed that the simple anastomotic technique is a good alternative technical option. Liang Z et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] reported both laparoscopic diamond-shaped and side-to-side duodenoduodenostomy showed good clinical results in the treatment of annular pancreas. They suggested the surgical techniques should be selected based on the surgeon’s experience, as well as the anatomy of duodenum.\u003c/p\u003e \u003cp\u003eOur team had compared the side-to-side and diamond-shaped duodenoduodenostomy in 2021 and found that side-to-side duodenoduodenostomy was benefit to the recovery of intestinal function postoperatively, with no complications during the mid-term follow-up period. We believed that the technique of laparoscopic side-to-side duodenoduodenostomy is safe and efficacious and can be a viable option for partial annular pancreas in the neonate at experienced center.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study aimed to demonstrate the diagnostic protocol of incomplete annular pancreas in neonates, as well as review the author’s personal experience and demonstrate the feasibility of the laparoscopic side-to-side duodenoduodenostomy for this rare entity. Due to low weight and the severity of the disease, CT, MRCP and ERCP are virtually impossible. So the diagnosis depends on the intraoperative findings mostly. It is important to detect and confirm the diagnosis of partial annular pancreas to avoid misdiagnosis and delay of the treatment. The results showed laparoscopic side-to-side duodenoduodenostomy could be performed safely and successfully in the neonates, even if the neonates coexisted with congenital intestinal malrotation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr Steven S. Rothenberg, The Rocky Mountain Hospital for Children for direction of our laparoscopic technique.\u003c/p\u003e\n\u003cp\u003eAuthors Contributions\u003c/p\u003e\n\u003cp\u003eLi Bing collected patients\u0026rsquo; records, drafted the article, and performed the review of the literature. Chen Wei-bing was involved in patient management and collected data. Xia Shun-lin was involved in the preparation and revision of the article.\u003c/p\u003e\n\u003cp\u003eDisclosure Statement\u003c/p\u003e\n\u003cp\u003eNo competing financial interests exist.\u003c/p\u003e\n\u003cp\u003eFunding Source\u003c/p\u003e\n\u003cp\u003eNo funding was secured for this study.\u003c/p\u003e\n\u003cp\u003eFinancial Disclosure\u003c/p\u003e\n\u003cp\u003eNo financial relationships relevant to this article to disclose.\u003c/p\u003e\n\u003cp\u003eConflict of Interest\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGfroerer S, Theilen TM, Fiegel HC, et al. Comparison of outcomes between complete and incomplete congenital duodenal obstruction. World J Gastroenterol 2019; 25:3787-3797. .\u003c/li\u003e\n\u003cli\u003eJensen AR, Short SS, Anselmo DM, et al. Laparoscopic versus open treatment of congenital duodenal obstruction: multicenter short-term outcomes analysis. J Laparoendosc Adv Surg Tech A. 2013; 23:876-80.\u003c/li\u003e\n\u003cli\u003eArora A, Mukund A, Thapar S, et al. Crocodile-jaw pancreas. Indian J Gastroenterol. 2012; 31(5):281. \u003c/li\u003e\n\u003cli\u003eBashir M, Ilyas M, Choh N, et al. Crocodile-jaw sign. Abdom Radiol (NY). 2018; 43(12):3534-3535. \u003c/li\u003e\n\u003cli\u003eXiang H, Han J, Ridley WE, et al. Crocodile jaw sign: Annular pancreas. J Med Imaging Radiat Oncol. 2018; 62 Suppl 1:69. \u003c/li\u003e\n\u003cli\u003eMittal S, Jindal G, Mittal A, et al. Partial annular pancreas. Proc (Bayl Univ Med Cent). 2016; 29(4):402-403. doi: 10.1080/08998280.2016.11929487.\u003c/li\u003e\n\u003cli\u003eKatwal S, Oli R, Bhusal A, et al. Partial annular pancreas as an incidental finding in a patient with intermittent bowel obstruction: A case report. Radiol Case Rep. 2023; 18(11):3968-3971. \u003c/li\u003e\n\u003cli\u003eSon TN, Liem NT, Kien HH. Laparoscopic simple oblique duodenoduodenostomy in management of congenital duodenal obstruction in children. J Laparoendosc Adv Surg Tech A. 2015; 25(2):163-6. \u003c/li\u003e\n\u003cli\u003eAli Almoamin HH, Kadhem SH, Saleh AM. Annular pancreas in neonates; Case series and review of literatures. Afr J Paediatr Surg. 2022; 19(2):97-101. \u003c/li\u003e\n\u003cli\u003eHill S, Koontz CS, Langness SM, et al. Laparoscopic versus open repair of congenital duodenal obstruction in infants. J Laparoendosc Adv Surg Tech A. 2011; 21(10): 961-3. \u003c/li\u003e\n\u003cli\u003eZhou Y, Li X. Investigation of annular pancreas through multiple detector spiral CT (MDCT) and MRI. J Appl Clin Med Phys. 2022; 23(1):e13487. \u003c/li\u003e\n\u003cli\u003eLi B, Chen WB, Wang SQ, et al. Laparoscopic diagnosis and treatment of neonates with duodenal obstruction associated with an annular pancreas: report of 11 cases. Surg Today. 2015; 45(1):17-21. \u003c/li\u003e\n\u003cli\u003ePuneet Mittal, Kamini Gupta, Amit Mittal, et al. Imaging findings in incomplete annular pancreas in adults with crocodile jaw appearance: Report of two cases. International Journal of Health \u0026amp; Allied Sciences. 2016; 5(4): 278\u003c/li\u003e\n\u003cli\u003eLi B, Chen BW, Xia LS. Laparoscopic side-toside duodenoduodenostomy versus diamond-shaped anastomosis for annular pancreas in the neonate. ANZ J. Surg 2021; 91:1504-8. DOI: 10.1111/ans.16959\u003c/li\u003e\n\u003cli\u003eOh C, Lee S, Lee SK, et al. Laparoscopic duodenoduodenostomy with parallel anastomosis for duodenal atresia. Surg Endosc. 2017: 31:2406-2410. \u003c/li\u003e\n\u003cli\u003eLiang Z, Lan M, Xu X, et al. Diamond-shaped versus side-to-side anastomotic duodenoduodenostomy in laparoscopic management of annular pancreas in children: a single-center retrospective comparative study. Transl Pediatr. 2023; 12(10):1791-1799.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopy, annular pancreas, crocodile jaw, side-to-side anastomosis, neonate","lastPublishedDoi":"10.21203/rs.3.rs-4226941/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4226941/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurposes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncomplete annular pancreas refers to the partial encircling of the second part of duodenum by pancreatic tissue anteriorly and posteriorly. The purpose of this manuscript is to report the rare configuration and the laparoscopic management strategy in neonates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe subjects for this study were 15 consecutive neonates with incomplete annular pancreas during January 2013 and September 2023. The distal duodenum was incised longitudinally and the proximal duodenum was incised transversely 1.0 cm away from the anterior ring of pancreatic tissue. The length of both the incisions was approximately 1.5-2.0 cm. Laparoscopic side-to-side duodenoduodenostomy was then carried out.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf all the patients, 6 were male and 9 were female. Crocodile jaw sign pancreas was revealed in all the neonates intraoperatively. Five of the neonates were diagnosed with an annular pancreas coexisting congenital intestinal malrotation, and Ladd’s procedures were performed firstly. Laparoscopic procedures were all completed without conversions. The mean operative time is 82.7 ± 17.5 min in the group (range, 50～120 min). The postoperative recovery was uneventful in all the cases. The mean follow-up duration was 39.9 ± 20.9 months (ranged, 6–60 months). There was not any anastomotic leak and stenosis in the series.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe rarely reported crocodile jaw sign pancreas should be recognized as a distinct type of annular pancreas and need to be given adequate attention clinically. The laparoscopic side-to-side duodenoduodenostomy is a safe and viable treatment option for experienced surgeons.\u003c/p\u003e","manuscriptTitle":"Laparoscopic treatment for incomplete annular pancreas in neonates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 20:43:50","doi":"10.21203/rs.3.rs-4226941/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"24d41ab3-df33-4274-b3e0-4af8ce325b44","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-17T20:43:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-17 20:43:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4226941","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4226941","identity":"rs-4226941","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}