**7. Treatment**

After the diagnosis of duodenal obstruction is established, a nasogastric tube should be inserted to decompress the stomach. Fluid resuscitation and electrolyte correction are important as well as monitoring the newborn's blood glucose level. Due to the expected delay in feeding postoperatively, we highly recommend placement of a peripherally inserted central catheter (PICC) for parenteral nutrition. Corrective surgery is not emergent unless malrotation is suspected.

Surgical treatment for duodenal atresia is duodenoduodenostomy to bypass the area of obstruction. The operation is classically performed via a right upper transverse laparotomy incision. Since the introduction of minimally invasive surgery, laparoscopy has been increasingly utilized for the repair of duodenal atresia with excellent outcomes [23–29]. Originally, side-to-side anastomosis was performed; however, diamondshaped duodenoduodenostomy was introduced by Kimura and was found to result in better outcomes, namely, earlier feeding, fewer anastomotic strictures, and better duodenal emptying [30–32]. After the abdomen is entered, the colon is mobilized to expose the duodenum. Associated malrotation should be ruled out at this step. The proximal dilated duodenum is easily mobilized. Other causes of duodenal obstruction, such as annular pancreas or preduodenal portal vein, may become obvious. The distal collapsed duodenum should be mobilized enough to gain length for a tension-free anastomosis. Before opening the duodenum, the surgeon should consider the windsock phenomenon. This phenomenon can be verified by asking the anaesthetist to push the nasogastric tube into the duodenum and observe the duodenal wall indentation, which marks the origin of the obstructing septum [13]. A transverse duodenotomy is made in the anterior wall of the distal part of the proximal duodenum with a similar length longitudinal duodenotomy made into the distal collapse duodenum. A diamond-shaped anastomosis is then constructed (**Figure 4**). The anastomosis should be tension-free and with an acceptable calibre. A tapering duodenoplasty is not routinely performed unless there is a concern about the emptying of a very dilated proximal duodenum [33, 34]. Some surgeons advocate the use of a transanastomotic feeding tube with the aim of early initiation of enteral feeding and limiting the use of parenteral nutrition [35, 36]. However, there are no well-designed prospective studies to examine the potential benefit of the use of transanastomotic feeding tube in duodenal atresia patients [37].

The laparoscopic approach to correct duodenal atresia was first described by Bax in 2000, and since then, it has gained wide popularity [23–26, 28, 29]. Three ports are usually needed. Liver retraction can be achieved by a transabdominal suture to retract the falciform ligament to better expose the duodenum. The anastomosis is performed using the standard technique. When compared with the open technique, several reports suggested an earlier feeding time and shorter time for parenteral nutrition and hospitalization after laparoscopic repair; however, there are no randomized controlled trials to support these findings [27, 38, 39].

**Figure 4.** *Diamond-shaped duodenoduodenostomy.*

Postoperatively, the newborn is monitored in the intensive care unit. Gastric decompression is continued until the output decreases and becomes less bilious. Until then, parenteral nutrition is provided via the PICC line. Contrast studies are not routinely required prior to the initiation of enteral feeding. The average length of hospital stay after duodenal atresia repair is approximately 23–33 days [40, 41]. In the era of enhanced recovery after surgery (ERAS), compelling evidence suggests that a well-designed ERAS protocol might result in earlier initiation of feeding and a shorter hospital stay without an increase in complications after repair for duodenal atresia [42].
