Prognostic factors for mortality in patients with congenital duodenal obstruction at DR. Moewardi Hospital Surakarta

Congenital duodenal obstruction is the most common congenital abnormalities in newborn. Almost 50% of all cases of congential abnormalities is duodenal obstruction. Several conditions of congenital obstruction can worsen a patient's prognosis, such as prematurity, low birth weight (LBW), other congenital abnormalities, type of obstruction, and the type of surgery performed.


| Research objectives
The aim of this study was to analyze prognostic factors for mortality in patients with congenital duodenal obstruction.

| Research benefits
The results of this study are expected to be used as a reference regarding the prognostic factors for mortality in patients with congenital duodenal obstruction so that it can be used in clinical practice to reduce mortality in cases of congenital duodenal obstruction.

| Definition
Congenital duodenal obstruction is a case of intestinal obstruction that often occurs in neonates. Congenital duodenal obstruction includes a range of disorders such as duodenal atresia, duodenal stenosis, annular pancreas, duodenal membrane, and preduodenal portal veins. 6

| Etiology
Congenital duodenal obstruction can be caused by intrinsic or extrinsic etiology of the duodenum. Intrinsic etiology includes atresia, intrinsic stenosis, and web/diaphragm with fenestration. Meanwhile, extrinsic etiology includes malrotation with Ladd band, midgut volvulus, annular pancreas, preduodenal portal vein, superior mesenteric artery syndrome, duplication cyst, and replaced right hepatic artery. 7

| Epidemiology
Congenital duodenal obstruction is one of the most common congenital anomalies in neonates, reaching 50% of all gastrointestinal disorders which are congenital. Congenital duodenal obstruction occurs in 1 in 2500 to 10 000 live births. 1

| Pathophysiology
There are intrinsic and extrinsic factors that are thought to cause duodenal malformations. The intrinsic factor that is thought to cause this anomaly is associated with the failure of the recanalization process of the intestinal lumen. This failure of recanalization is known as duodenal atresia. 8 Recanalization of the abdominal lumen will occur afterward. If there is a failure in this process, the duodenal lumen will experience narrowing. Duodenal obstruction is associated with the incidence of annular pancreatic malformation. 8,9

| Classification
Based on the malformation process that occurs, congenital duodenal obstruction is classified into total obstruction and partial obstruction ( Figure 1). Mortality in this case was associated with congenital heart disease. The grade of duodenal obstruction is said to have an impact on postoperative outcomes. 3,4,10 Total obstruction The category of obstruction consists of duodenal atresia types 1 to 3 which may be accompanied by anomalies of the annular pancreas.
The manifestations of duodenal obstruction in the total obstruction subgroup were detectable since pregnancy. Surgical procedures in this subgroup tend to be longer, starting from the preparation stage to the postoperative stage. Patients in this subgroup had longer hospital stays, with a higher morbidity rate when compared with the partial obstruction subgroup (Figure 1). 4,10

Partial obstruction
The category of obstruction consists of net-type obstruction (perforated diaphragm), anomalies in the Ladd band, annular pancreas, preduodenal portal vein, superior mesenteric artery syndrome, and duplicated cysts. This has an impact on treatment which tends to be slower so that it can increase the morbidity rate. 3,4

| Clinical manifestations
The clinical manifestations found in neonates with congenital duodenal obstruction are not described specifically and cannot narrow down the differential diagnosis significantly. Most of the neonates who present with congenital duodenal obstruction present with the manifestation of bilious vomiting and a minority of cases are accompanied by abdominal distension. The clinical manifestations present in patients with late-onset (appearing in the elderly) are often more nonspecific, such as abdominal pain, nausea, vomiting, or diarrhea. 11

| Diagnosis
The diagnosis can be made based on radiological imaging findings.
The finding of true double bubble ( Figure 2) or dilated multiple bowel loops is a characteristic feature of imaging congenital duodenal obstruction so that the diagnosis can be made, and management of the patient can be started immediately. If these criteria are included, then the diagnosis can be made. 11

| Management
Exploratory laparotomy is needed immediately in children with manifestations of bilious vomiting and proximal abdominal radiograph shows malrotation with or without volvulus midgut. [11][12][13] Currently the procedure of choice is currently a duodenoduodenostomy. Treatment of obstruction accompanied by anomalous pancreatic annular should be accompanied by a bypass procedure. The duodenojejunostomy procedure has shown good results in cases refractory to conservative management. Duodenum tissue can be repaired with duodenotomy or duodenoplasty procedures. Postoperative complications that may occur include megaduodenum with functional obstruction, cholestatic jaundice, gastroesophageal reflux, and anastomotic strictures. 11,14

| PROGNOSIS FACTORS OF MORTALITY
In congenital duodenal obstruction, several conditions can worsen the patient's prognosis, such as prematurity, low birth weight (LBW), and other congenital abnormalities. In addition, several other factors that are thought to influence patient morbidity and mortality are the type of obstruction and the type of surgery that performed. 15

| Gestational Age
Almost half of the patients with congenital duodenal obstruction are born prematurely. Kumar et al found that preterm pregnancy had a significant effect on child mortality. This is thought to be associated with the incidence of polyhydramnios. 1,16 F I G U R E 1 Abdominal radiograph images of total obstruction (A) and partial obstruction (B). 11 F I G U R E 2 True double bubble 11 3.2 | Birth weight Low birth weight (<2500 g), which is also associated with prematurity, has a significant association with congenital mortality of gastrointestinal anomaly congenital disorders. 6

| Types of obstruction
In a study by Gfroerer et al, total duodenal obstruction is closely associated with lower gestational age, lower birth weight, congenital heart defects, higher morbidity, and more complications compared with partial duodenal obstruction. Mortality is found more in total obstruction, with heart defects as the main cause of death. 4 4 | CONCEPTUAL FRAMEWORK

| Description of the conceptual framework
Congenital duodenal obstruction consists of two types, total and partial obstructions (Figure 3). This disorder is often accompanied by other congenital abnormalities such as down syndrome and congenital heart defects. Some of the risk factors for congenital duodenal obstruction are preterm pregnancy and low birth weight. Several types of surgery can be performed for congenital duodenal obstruction, such as gastrojejunostomy, duodenojejunostomy, and duodenoduodenostomy. 2,18 This study aims to identify the above factors and their influence on mortality prognosis in patients with congenital duodenal obstruction.
All data were sourced from treated pediatric patients with duodenal obstruction at Dr. Moewardi Hospital, Surakarta, in January 2019 to December 2020, who were grouped according to the type of obstruction, gestational age, birth weight, and other congenital abnormalities. The data were then processed to see whether the type of obstruction influenced patient mortality.

| RESEARCH METHODOLOGY
This research was a retrospective descriptive study with crosssectional approach.

| Study sample
All pediatric patients with congenital duodenal obstruction who admitted to Dr. Moewardi Hospital, Surakarta, in January 2019 to December 2020 were included as the sample.

| Method of sampling
Data were taken from the medical record of pediatric patients with duodenal obstruction who were treated at Dr. Moewardi Hospital, Surakarta, from January 2019 to December 2020. The medical record data of the patients taken were diagnosis, gestational age, birth weight, and other congenital abnormalities.

| Data analysis
The research data obtained were processed using SPSS 25.0. To find the effect of the type of obstruction on patient mortality, One-Way Fisher's Exact test was performed.

| Inclusion criteria
The inclusion criteria of this study were patients diagnosed with duodenal obstruction based on clinical symptoms and babygram imaging who were treated in Dr. Moewardi Hospital, Surakarta, in January 2019 to December 2020.

| Exclusion criteria
The exclusion criteria of this study was congenital obstruction other than duodenal obstruction. F I G U R E 3 Research conceptual framework

| Research variables
In this study, the variables of the study were the type of obstruction, gestational age, birth weight, and other congenital abnormalities.

| RESULTS
The number of duodenal obstruction patients in this study were 20 samples (Table 1).
In Table 2 was found that more patients with total obstruction died (81.8%) than patients with partial obstruction (18.2%). The results of the comparative test also showed statistically significant data (P = 0.04) while other variables did not show statistically significant differences in data.

| DISCUSSION
Duodenal obstruction is one of the most common causes of infant intestinal obstruction. About half of all intestinal obstructions are caused by intestinal duodenal atresia and the other half by stenosis. 19,20 In this study, it was found that 60% of the samples were of the total obstruction type, and as many as 55% of patients with duodenal obstruction died. Brantberg  or had substantial developmental impairments. A total of 10 of the