Pediatr Surg Int (2011) 27:437–442
DOI 10.1007/s00383-010-2729-8
ORIGINAL ARTICLE
Comparative outcomes in intestinal atresia:
a clinical outcome and pathophysiology analysis
Sathyaprasad Burjonrappa • Elise Crete •
Sarah Bouchard
Accepted: 26 August 2010 / Published online: 4 September 2010
Ó Springer-Verlag 2010
Abstract
Objective To describe the outcomes of 130 intestinal
atresias between 1982 and 2007.
Methods Records were analyzed for location, demo-
graphics, prenatal diagnosis, birth weight, associated
anomalies, surgery, establishment of oral intake, re-inter-
ventions and mortality. Statistical analyses were performed
using Fisher test and ANOVA.
Results There were 59 duodenal (30 male), 63 jejuno-
ileal (34 male) and 8 colonic atresias (3 male). Prenatal
diagnosis was established in 27 (46%) duodenal (DA), 26
(41%) jejuno-ileal (JIA) and 1 (12.5%) colonic atresias
(CA). The mean birth weights, 2,380.5 g (SD 988) DA,
2,814 g (SD 755) JIA and 3,153 g (SD 527) CA were
significantly different (p = 0.011). The mean gestational
ages were 36, 37 and 37 weeks in DA, JIA and CA,
respectively (p-NS). Associated congenital anomalies were
seen in 41 (76%) DA, 32 (52%) JIA and 3 (38%) CA
(p = 0.08, NS). The median time to full oral feeds after
surgery was 18 days in DA, 20 days in JIA and 15.6 days
in CA, respectively (p [ 0.05). Eight patients with DA and
nine patients with JIA underwent repeat surgery for adhe-
sive obstruction. Adhesive bowel obstruction was most
common in the first year after surgery in both groups
(15/17). Gastroschisis was seen in six (10%) of JIA
and three (35%) of CA. Two patients in the JIA group
S. Burjonrappa (&)
Division of Pediatric Surgery, Department of Surgery,
New York Medical College, 321 Munger Pavilion,
Valhalla, New York, NY 10595, USA
e-mail: sathyabc@yahoo.com
S. Burjonrappa
E. Crete
S. Bouchard
Hospital Ste Justine, University of Montreal,
Montreal, QC H3T 1C5, Canada
underwent bowel lengthening. Patients with gastroschisis
and those with associated anomalies needed prolonged
duration of TPN after JIA correction. There was no mor-
tality in the duodenal atresia and colonic atresia groups. Six
patients in the JIA group died, three of severe atresias
coupled with multiple anomalies and three of cholestasis
and sepsis.
Conclusion Distal atresias are difficult to diagnose ante-
natally. Proximal atresias have a significantly lower birth
weight than distal atresias. Associated anomaly screening
is important in all atresias.
Keywords Intestinal atresia
Duodenal atresia

Colon atresia
Introduction
Intestinal atresias are one of the most common causes of
intestinal obstruction in the neonate with an incidence of 1
in 5,000 newborns [1, 2]. The prognosis for this condition
has improved significantly since the early 1970s [2–4]. This
improvement has coincided with advances in diagnostic
modalities, surgical technique, neonatal intensive care and
parenteral nutrition. We present our results in this condition
comparing the incidence of specific clinical features and
surgical outcomes in the different subsets of atresias.
Materials and methods
A retrospective chart review of all infants undergoing sur-
gical correction of intestinal atresia over a 25-year period
(1983–2008) was conducted at our tertiary care institution
after obtaining institutional review board approval.
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Duodenal atresia diagnosis was based on identifying an
antenatal double bubble on ultrasound or on plain X-ray
demonstration of the double bubble sign postnatally. The
stomach was decompressed with a replogle tube, while
cardiac defects were excluded by an echocardiogram. After
adequate evaluation of other associated congenital anoma-
lies, surgical repair was planned. All repairs of this anomaly
were performed through a right upper quadrant transverse
laparotomy. Location of ampulla of vater was confirmed by
gentle compression of the gallbladder prior to repair. We
confirmed the absence of concomitant distal atresias by
placing a feeding tube in the duodenotomy and confirming
free passage of irrigated fluid to the cecum. A windsock
deformity was excluded by ensuring that the nasogastric tube
could be manipulated through the proximal duodenotomy.
The management of duodenal atresia at our institution
involved a duodeno-duodenostomy of the side-to-side type, a
diamond-shaped anastomosis, a conservative web excision,
and in the more distal types of duodenal atresias a duodeno-
jejunostomy. Oral intake was permitted once the nasogastric
aspirate had decreased and bowel function returned. No
trans-anastomotic tubes were used in any of our patients.
For the more common jejuno-ileal atresias, we always
performed a water-soluble contrast enema to exclude any
concomitant colonic atresia after establishing the diagnosis
of small bowel obstruction by supine and decubitus views of
the abdomen. Atresias were classified based on the Grosfeld
modification of the intestinal atresia classification [5]. In the
type I (web), II (fibrous cord) and IIIA (mesenteric defect)
atresias, an end-to-end anastomosis was the most com-
monly performed procedure with or without tapering of the
dilated proximal bowel. Bowel length conservation was
more important in the more complicated type IIIB (apple
peel) and type IV (multiple) atresias. We anastomosed the
Table 1 Clinical characteristics of neonates born with intestinal atresia
Clinical feature Duodenal atresia
(n = 59)
Prenatal diagnosis 27 (46%)
Sex (M:F) 29:30
Mean gestational age (weeks) 36
Birth weight* 2,380.5 g (SD 988)
Associated anomalies 41 (76%)
Mean duration of parenteral nutritive support (days) 18
Incidence of reoperation 8 (13.5%)
Adhesive bowel obstruction 7 (12%)
Duration of hospital stay (mean days) 32.6 (95% CI 29–42)
Follow-up (years) 1 year (1–8)
Mortality 0 7 (11%)
* Denotes a statistically significant difference in p values
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Pediatr Surg Int (2011) 27:437–442
dilated proximal bowel to the distal apple peel based on the
often tenuous ileo-colic branch. Anastomosis over inert
silastic tubing was used in multiple atresias. For the rare
colonic atresia, a primary anastomosis was performed for
right-sided lesions and a colostomy was performed for left-
sided lesions (splenic flexure and beyond) during the initial
operation. Infants with gastroschisis were excluded from
the evaluation of differences in birth weight.
Oral intake was allowed once bowel function returned.
All neonates were supported with parenteral nutrition until
goal calories were achieved by oral intake. The feeding
regimens remained the same over the study period but the
formulas available for infants with short bowel were
changed. We started feeds slowly in these premature
infants and increased the rate first and increased osmolarity
(concentration) of feeds [if needed] only after goal rates
had been achieved and tolerated. Most neonates were
gavage fed until they were mature enough to swallow.
Data collection included prenatal diagnosis, demo-
graphics, birth weight, gestational age, presenting symp-
toms, associated abnormalities, incidence of abdominal
wall defects, radiological findings, surgical intervention,
morbidity, surgical re-intervention, time to establishment
of full oral intake, length of hospital stay and mortality.
The Fisher test was used to test the significance of differ-
ences in categorical data, while the student’s t test and
ANOVA were used to analyze the significance of differ-
ences between continuous variables.
Results
A total of 130 atresias were repaired during the study
period. Table 1 illustrates the various clinical features of
Jejuno-ileal atresia Colonic atresia
(n = 63) (n = 8)
26 (41%) 1 (12.5%)
34:29 3:5
37 37
2,814 g (SD 755) 3,153 g (SD 527)
32 (52%) 3 (38%)
20 15.6
16 (25%) 2 (25%)
9 (14%) 0
41 (95% CI 30–63) 43.50 (95% CI -9 to 96)
1.7 years (0.5–11) 2.5 years (0.5–8)
0
Pediatr Surg Int (2011) 27:437–442
Table 2 Incidence of
Associated anomaly
associated anomalies in
neonates born with intestinal
atresia Down’s syndrome
Structural cardiac defects
Malrotation
a
The miscellaneous grouping Gastroschisis
includes: omphalocele, Vertebral defects and scoliosis
umbilical cord hernia, endocrine Genitourinary
abnormalities, rare syndromes,
Neurological
choledochal cysts and other
hepato-biliary malformations, Cleft lip/palate
other digestive tract Tracheo-esophageal fistula
malformations, intra-uterine Miscellaneousa
growth retardation (IUGR), etc.
the three groups. The male to female ratios in duodenal
atresia were 1:1 (29 male, 30 female), in jejuno-ileal atresia
1.17:1 (34 male, 29 female), and in colonic atresia 0.6:1
(3 male, 5 female). Antenatal diagnosis was established in
27 of 59 babies (46%) with duodenal atresia, 26 of 63
(41%) with jejuno-ileal atresia and 1 of 8 (12.5%) with
colonic atresias (p [ 0.05). The prenatal ultrasound find-
ings included ultrasound ‘‘double bubble’’ in duodenal
atresia, dilated echogenic bowel loops in jejuno-ileal and
colonic atresias, and polyhydramnios in a proportion of
both proximal and distal atresias. The mean gestational
ages were 36 weeks in duodenal atresia, 37 weeks in je-
juno-ileal atresia, and 37 weeks in colonic atresia. The
mean birth weights (excluding those with gastroschisis)
were 2,380.5 g (SD 988) in duodenal atresia, 2,814 g (SD
755) in jejuno-ileal atresia, and 3,153 g (SD 527) in
colonic atresia (p = 0.011). In the jejuno-ileal atresia
group, there were 14 type I, 14 type II, 16 type IIIA, 9 type
IIIB and 10 type IV atresias. In the colonic atresia group,
four had a type I lesion and four had a type II defect.
Associated anomalies were seen in 41 (76%) patients with
duodenal atresia, 32 (52%) with jejuno-ileal atresia, and 3
(38%) with colonic atresias (p [ 0.05). Down’s syndrome
was seen in 18 (31%) of the patients with duodenal atresia.
In this series, gastroschisis was observed in ten infants with
colonic and jejuno-ileal atresia (14%). Seven of these
infants had jejuno-ileal atresia, one had a colonic atresia,
and two had atresias in both the colon and the small
intestine. Table 2 illustrates the incidence of different
congenital anomalies among the three groups.
In the duodenal atresia group, bilious vomiting was the
most frequent mode of presentation, while in the colonic
atresia group abdominal distension was the most frequent
presentation with vomiting being a late feature. Other
presentations in duodenal atresia included loss of weight or
failure to gain weight (8%), abdominal distension sec-
ondary to gastric dilatation (14%), aspiration (3%), and
delayed passage of meconium (3%). The presentation in
439
Duodenal atresia Jejuno-ileal atresia Colonic atresia
(n = 59) (n = 63) (n = 8)
18 (31%) 0 0
29 (49%) 12 (19%) 2 (25%)
17 (29%) 8 (13%) 0
0 7 (11%) 3 (37.5%)
2 (3%) 0 1 (12.5%)
2 (3%) 3 (5%) 0
3 (5%) 4 (6%) 0
3 (5%) 0 0
3 (5%) 2 (3%) 0
11 (19%) 13 (21%) 3 (37.5%)
the jejuno-ileal atresia group was more variable and was
dependent on its location vis-à-vis the duodenum. Of the 30
patients with more proximal atresias, a majority presented
with bilious emesis while abdominal distension was the
more common presentation in the 33 patients with distal
small bowel atresia. Duodenal atresia was diagnosed clin-
ically and confirmed by plain X-ray. An upper GI was
performed rarely and only in instances where the child was
older and malrotation with volvulus was a possibility. All
patients with jejuno-ileal and colonic atresias underwent
water-soluble contrast enemas to define colonic anatomy.
Of the colonic atresias, three were in the right colon, two
were in the transverse colon, and three were in the sigmoid
colon.
In neonates with duodenal atresia, duodeno-duodenos-
tomy was the most frequently performed procedure and
was performed in 50 patients. Duodenojejunostomy was
done in four patients and a conservative web excision, with
preservation of the medial wall, was performed in four
others. Resection and anastomosis was performed in one
patient. Ten infants who had duodenal atresia needed re-
hospitalization secondary to complications related to the
initial operation. Eight of these patients were re-operated
upon, while one underwent radiology guided balloon
dilatation for anastomotic stenosis and the other had three
admissions for adhesive sub acute bowel obstructions that
were conservatively managed. Of the eight re-operations,
six (10%) needed surgery (lysis of adhesions) due to
adhesive bowel obstruction, one needed a re-exploration
for anastomotic stenosis, and the last patient needed re-
exploration for a missed distal atresia. In neonates with
jejuno-ileal atresia, 52 underwent resection and end-to-end
anastomosis, five patients underwent a Bishop-Koop pro-
cedure, and five had a stoma created. One patient with
gastroschisis and a known atresia developed total small
bowel necrosis and underwent an exploration and closure
only. Primary tapering (at the initial operation) was per-
formed in four patients (6%). Nine patients (14%) needed
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re-exploration for adhesive bowel obstruction and one
patient needed re-intervention for an anastomotic leak.
Intestinal dilatation developed in 7 of 63 patients (11%).
A surgical re-exploration and tapering was performed in
five patients at 16, 18, 22, 28 and 90 days after the initial
atresia surgery due to feeding intolerance and functional
obstruction on oral contrast studies. Two patients, one with
a type IIIB and the other with a type IV atresia and bowel
dilatation underwent a Bianchi [6] and STEP [7] procedure
with good results. The Bianchi procedure was done at
1 year and 9 months of age and the STEP (serial transverse
enteroplasty) procedure at 3 years of age. In the colonic
atresia group, five underwent resection and anastomosis
and three underwent a Bishop-Koop procedure (end-to-side
anastomosis with the end of the distal bowel being exte-
riorized as a chimney). One patient needed revision of the
end-to-side colonic anastomosis at the time of the Bishop-
Koop closure due to stenosis.
Time to full oral intake was less than 2 weeks in nearly
45% of neonates with duodenal atresia. In the jejuno-ileal
atresia group, the mean duration on parenteral nutrition was
20 days (SD 17.8, third quartile = 22.75). Anyone on
nutritive support for longer than 40 days was considered an
outlier based on the Tukey’s test of variance. There were
11 outliers based on the Tukey test. Six of them had gas-
troschisis, one had a choledochal cyst, one had associated
cardiac anomalies, one had a high output stoma, and one
neonate had a complex syndrome (syndrome of Kamour-
aska: an autosomal recessive condition associated with
peripheral neuropathy, psychomotor retardation, chronic
diarrhea and increased long chain fatty acids). In the
colonic atresia group, average duration of parenteral
nutrition requirement was 78 days in the group with gas-
troschisis and 11 days in the group without.
Infants with duodenal atresia had an excellent prognosis
with no mortality in our series. The mean duration of
hospitalization was 32.6 days (SD = 34.6 days) and the
mean surgical follow-up was 12.5 months (SD = 15.8).
Trisomy 21 was not associated with poor prognosis.
Associated anomalies (p = 0.0015), prematurity
(p = 0.0119) and low birth weight (p = 0.0110) increase
the duration of hospitalization without affecting survival.
In the jejuno-ileal atresia group, the average hospital stay
was 41 days (8–322 days; 95% CI 30.3–63.1). Outliers
determined based on the Tukey test were patients with a
stay greater than 98 days. There were four patients with
significantly longer inpatient stay. Two of these patients
had gastroschisis and two others had apple peel atresias
(type IIIB). The overall mortality rate in the jejuno-ileal
atresia group was 11%. Most patients who died had asso-
ciated anomalies (p = 0.017) or type IIIB/IV atresias
(p = 0.007). There were three in-hospital deaths due to
severe atresias and multiple anomalies. The anomalies
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Pediatr Surg Int (2011) 27:437–442
included porencephaly (1), absent septum pellucidum and
gastroschisis (1), and structural cardiac defect (1). Three
infants died due to complications linked to parenteral
nutrition-related cholestasis and sepsis. These were late
deaths occurring at 1.6, 2 and 3 years after initial surgery.
In this group too, two patients had associated anomalies
including a choledochal cyst (1) and the syndrome of
Kamouraska (1). One patient with type IIIA jejuno-ileal
atresia died 2.5 months after surgery due to sepsis from an
undetermined source after an uneventful recovery from
surgery. In the colonic atresia group, the average duration
of hospital stay was 98 days in those with abdominal wall
defects and 10 days in the group without. There was no
mortality in this group.
Discussion
Nearly one-third of all congenital bowel obstructions are
due to intestinal atresia [1, 2]. The etiology of this condi-
tion is thought to be secondary to incomplete vacuolization
of the solid primitive duodenum [8] and secondary to
vascular or mechanical accidents in the case of the jeju-
num/ileum and colon [9]. Our accuracy in detecting small
bowel atresias is around 45% and this compares favorably
with another series with similarly collected data and
accuracy rates of between 23 and 31% [12]. In our expe-
rience, all signs of intestinal obstruction (stomach ‘‘double
bubble’’, dilated echogenic loops [7 mm in internal
diameter and free peritoneal fluid) are most accurately
detected from the late second trimester onward. This
coincides with the process of the return of the intestine
back into the coelomic cavity from the physiological her-
niation into the extraembryonic coelom (10–12 weeks of
intra-uterine life). The critical sequence of events at this
point of time involves intestinal rotation and fixation and
hence lends credence to our hypothesis that the association
between malrotation and atresia may be due to an abnor-
mality in this physiological process. Similar results have
been described by others [10, 11]. Further, our study
reaffirms that proximal intestinal obstruction appears to be
detected more easily than obstruction further distally in the
intestinal tract. This is explained by the ability of the colon
to absorb fluid, thereby preventing significant intestinal
dilatation in distal obstruction [13].
There was a significant difference in birth weight of
nearly 400 g between atresias at different levels in the
intestine. This could not be explained on the basis of
maternal factors, prematurity or growth restriction because
of associated congenital anomalies, which were not sig-
nificantly different between groups. Our study was the first
to associate the length of mucosal surface to higher birth
weight [14]. Inter-related work by Blakelock et al.
Pediatr Surg Int (2011) 27:437–442
demonstrated that term babies born with gastroschisis are
significantly growth retarded compared with premature
babies born with gastroschisis. Term babies born with a
proximal intestinal atresia in gastroschisis were also
growth retarded, which suggested that in late gestation, the
normal growth is dependent on a normally functioning
gastrointestinal tract that allows exposure of the proximal
intestinal mucosa to ingested amniotic fluid [15]. Others
have also shown greater growth retardation in neonates
with jejunal as compared to ileal atresia [16, 17]. We
hypothesize, based on our clinical observations to date, of a
possible entero–endocrine axis that contributes to fetal
weight gain beyond the third trimester. We suggest that the
amniotic fluid glucose and insulinogenic amino acids (such
as ornithine and arginine found in high concentrations in
the amniotic fluid) play an important role in regulating fetal
insulin levels through modulation of incretin peptides
GLP-1 (glucagon-like peptide) and GIP (glucose-dependent
insulinogenic peptide). It is well established that GLP is
secreted by K cells located in the proximal duodenum,
while the L-cells that secrete GIP are located in the distal
small intestine and colon [18]. We suspect that because of
the ability of these specialized mucosal cells to increase
beta cell mass and promote insulin release, they play an
important role in the fetus in promoting third trimester
weight gain. Our observation of distal atresias having
greater weights than proximal atresias supports this ana-
tomic distribution of incretin peptides in the intestine.
Associated anomalies were observed in nearly 75% of
infants with duodenal atresia. This is higher than the inci-
dence of associated anomalies noted in about 50% of new-
borns analyzed in another large series published recently
[19]. Nearly one-third of these neonates have Down’s syn-
drome, but their prognosis is no worse than those without the
condition. A similar observation has been reported by others
[20]. Further research is needed to explain the overall high
incidence of associated anomalies (52%) in the jejuno-ileal
atresia group. We suspect that based on earlier work done in
this geographic area, there is a higher incidence of genetic
transmission of intestinal atresia [21].
In duodenal atresias, duodeno-duodenostomy is the
operation of choice and avoids the complications of duo-
deno-jejunostomy including delayed anastomotic function
and blind loop syndrome that have been reported from our
center earlier [22]. Based on our experience, tapering should
be performed at the initial exploration if there is significant
luminal disparity between the two ends, particularly in the
proximal jejunal atresias. Other options include resection of
the dilated bowel up to normal caliber and perform anas-
tomosis at that level. This would be applicable in infants
with adequate bowel length. The Bishop-Koop procedure is
an option for more distal atresias with a significant luminal
disparity and helps conserve mucosal absorptive surface.
441
Adhesive bowel obstruction remains a significant cause of
morbidity after surgery for intestinal atresia. In this series,
around 12% of the neonates needed re-operative surgery for
bowel obstruction after atresia correction. These figures are
similar to another large series [10]. The clinical presentation
of bowel obstruction could theoretically occur at any point,
but interestingly in our series of jejuno-ileal atresia all
presented within the first year after atresia correction. Bowel
dilatation may be a blessing in disguise for infants with short
bowel syndrome allowing for bowel lengthening procedures
such as the STEP or Bianchi.
There was no significant difference between atresia
subgroups in the time to cessation of parenteral nutrition.
Intestinal atresia associated with gastroschisis caused a
significant prolongation in the duration of parenteral
nutrition requirement and hospital stay. Length of hospital
stay was also significantly prolonged in patients with
intestinal atresia and prematurity or in the presence of
significant associated anomalies. The mortality in our ser-
ies was observed only in the jejuno-ileal atresia group
(11%). This is similar to data from other series [1, 2, 10].
Improvement in neonatal care and enteral and parenteral
nutrition technology has significantly improved the prog-
nosis in these neonates.
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