Natural orifice endoluminal technique (NOEL) for the management of congenital duodenal membranes

Abstract

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Therapeutic Upper Gastrointestinal Endoscopy in Pediatric Gastroenterology

“…Congenital duodenal membranes, also known as duodenal webs, are a rare condition with an estimated incidence of 1/10,000-40,000 birth and are often associated with genetic, cardiovascular, or GI abnormalities and are particularly prevalent in syndromes such as Down's or 22q deletion (104). In the case of complete obstruction or atresia, it is usually diagnosed antenatally or soon after birth, but if obstruction is incomplete, diagnosis might be made later in life.…”

“…Traditionally, treatment was surgical (either laparoscopic or open), but several endoscopic techniques have emerged in the last decade, including endoluminal balloon dilatation, the use of division by sphincterotome, and laser ablation. A combination of endoscopic balloon dilatation and electrocautery endo-knife (MicroKnife, Boston Scientific Microinvasive, Natick, MA, USA)/sphincterotome (Cook MiniTome, Bloomington, IN, USA) has recently been described in 15 children, but this has graduated to balloon dilation only as the use of the endo-knife can be associated with inadvertent perforation of the pancreaticobiliary radicle, which is anatomically opposed to the membrane (104). It is crucial to always check for a secondary, more distal membrane, as this has been observed in up to 20% of cases (104).…”

“…A combination of endoscopic balloon dilatation and electrocautery endo-knife (MicroKnife, Boston Scientific Microinvasive, Natick, MA, USA)/sphincterotome (Cook MiniTome, Bloomington, IN, USA) has recently been described in 15 children, but this has graduated to balloon dilation only as the use of the endo-knife can be associated with inadvertent perforation of the pancreaticobiliary radicle, which is anatomically opposed to the membrane (104). It is crucial to always check for a secondary, more distal membrane, as this has been observed in up to 20% of cases (104). A single intervention has been sufficient in 60% of the cases, but some of the patients might need a second or third procedure (8).…”

“…A single intervention has been sufficient in 60% of the cases, but some of the patients might need a second or third procedure (8). Cases requiring supplementary procedures have been related to the presence of the annular pancreas; hence, Thomson et al have suggested performing an MRCP prior to the endoscopic procedure-this may highlight the relative position of the ampulla of Vater to the web and suggest whether balloon dilation or balloon and dissection by an endo-knife will be the approach of choice (104).…”

Successful management of membranous duodenal stenosis by endoscopic balloon dilation and membrane resection with an insulated-tip knife

“…Membranous duodenal stenosis is a common pediatric gastrointestinal abnormality, with an incidence of 1:10 000-40 000 [1], which has traditionally been managed either via laparotomy or laparoscopic surgery. Endoscopic treatment of sporadic cases has been reported [2][3][4]. However, balloon dilation alone, without membranectomy, may result in stricture recurrence, whereas membranectomy cutting techniques cannot completely avoid possible injury to the duodenal papilla or even perforation, especially if the duodenal papilla is below the membrane.…”