Malrotation of midgut in adults, an unsuspected and neglected condition--An analysis of 64 consensus confirmed cases

Diagnosis of adult midgut malrotation in CT: sign of absent retromesenteric duodenum reliable

OBJECTIVES

To compare the incidence of absent retromesenteric duodenum with other radiological signs and to assess its diagnostic significance for midgut malrotation in adults.

METHODS

This IRB-approved retrospective single-center study involved adult patients who underwent abdominal CT scans. Patients were screened for the presence of the absent retromesenteric duodenum sign. Signs observed included the position of the duodenal-jejunal junction (DJJ) and jejunum within the abdomen, the relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), the locations of the ascending colon, cecum, and appendix, and the presence of intestinal volvulus.

RESULTS

A total of 5594 patients were included. Seven patients exhibited the sign of absent retromesenteric duodenum. Four of these patients were identified as those diagnosed with midgut malrotation in the past five years. The common features observed in all 11 patients were: the horizontal segment of the duodenum did not traverse behind the SMA but instead curved rightwards and forwards adjacent to it; the DJJ and jejunum were positioned in the right abdomen; the SMV was anterior to the SMA. In 7 patients (7/11), the ascending colon, cecum, and appendix were located in the left abdomen. 5 patients (5/11) showed a high cecum position, and 2 patients (2/11) exhibited a pelvic appendix.

CONCLUSION

The absent retromesenteric duodenum sign in CT diagnosis of adult midgut malrotation has proven to be more reliable.

CRITICAL RELEVANCE STATEMENT

Radiologists should routinely identify the course of the duodenum horizontal segment in CT images, to prevent misdiagnosis of adult midgut malrotation.

KEY POINTS

CT is suitable for the diagnosis of adult midgut malrotation. Absent retromesenteric duodenum for diagnosing adult midgut malrotation is more reliable than other signs. Diagnostic CT criteria for adult midgut malrotation need updating.

Adult Presentations of Congenital Midgut Malrotation: A Systematic Review

BACKGROUND

Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation.

METHODS

A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed.

RESULTS

Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively).

CONCLUSION

Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.

Recurrent midgut volvulus in an adult patient - The case for pexy? A case report and review of the literature

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Intestinal malrotation and midgut volvulus in adulthood are rare events.

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Reports of recurrence among adults are very scarce. The rate of recurrence and optimal surgical management are yet to be determined.

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Bowel fixation procedures may be considered in Ladd procedures for adult midgut volvulus in order to reduce recurrence.

Introduction

Intestinal malrotation is a rare condition, with an incidence estimated between 0,2 to 1%. Most cases are diagnosed and treated during childhood. Adult presentations are rare and most adults present with chronic nonspecific complaints.

Midgut volvulus is the most feared complication of intestinal malrotation, far more common among the pediatric than the adult population. Presentation in adulthood with a midgut volvulus accounts for a minority of these patients (15%).

The Ladd procedure is the standard surgical management of midgut volvulus and intestinal malrotation. Most evidence on the outcomes of the Ladd procedure originates from studies on pediatric population and the recurrence among children who have had a Ladd procedure is low (2–7%).

Presentation of case

We report an exceedingly rare case of a patient who presented in adulthood with a midgut volvulus and less than two years after undergoing Ladd procedure presented with a recurrence of the midgut volvulus. The recurrent midgut volvulus was successfully treated by a fixation procedure (cecopexy and duodenopexy).

Conclusion

Reports of midgut volvulus in adult patients are scarce and reports of recurrence even scarcer hence the rate of recurrence among adult patients has yet to be determined. The recurrence rate in some of the available adult series is much higher than the rate reported among children.

Should the rate of recurrence among adult patients prove higher, it poses the question of whether the Ladd procedure should be modified to include bowel fixation when performed in adults.

Short bowel syndrome caused by laparoscopic loop enterostomy of the jejunum in an adult with undiagnosed intestinal malrotation: A case report

RATIONALE

Failure to recognize intestinal malrotation in adults can cause complications during surgeries, especially those with a limited operative field. We report a case of short bowel syndrome caused by mistaken creation of a loop enterostomy in the jejunum due to undiagnosed intestinal malrotation.

PATIENT CONCERNS

A 72-year-old man underwent a laparoscopic right hemicolectomy and ileocolostomy because of complicated diverticulitis. Six days after the surgery, he received laparoscopic exploration because of anastomotic leak, and a laparoscopic loop ileostomy was also performed as a protective diversion stoma. One month after surgery, he complained of severe diarrhea from the enterostomy after food and water intake. An upper gastrointestinal and small bowel series revealed that the duodenojejunal junction (DJJ) did not cross the midline and there was a short distance between the DJJ and the enterostomy in the right lower quadrant.

DIAGNOSES

Short bowel syndrome caused by mistaken creation of a loop enterostomy in the jejunum due to undiagnosed intestinal malrotation.

INTERVENTIONS

Total parental nutrition was used and the loop enterostomy was closed 3 months after the initial surgery.

OUTCOMES

The patient was discharged uneventfully 2 weeks after the loop enterostomy.

LESSONS

Intestinal malrotation in adults is often encountered during routine radiological examinations. However, it may cause complications during surgery if ignored. Radiologists should keep in mind that complications may occur if a complete presurgical evaluation of intestinal malrotation is not performed, and surgeons should take caution when performing surgeries, especially those with a limited operative field.