1
|
Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
Collapse
Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| |
Collapse
|
2
|
Devkota S, Luitel P, Paudel S, Neupane N, Dev S, Kansakar PBS. Incidentally discovered intestinal malrotation during evaluation for blunt abdominal trauma: A case report. Int J Surg Case Rep 2024; 116:109430. [PMID: 38428056 PMCID: PMC10944091 DOI: 10.1016/j.ijscr.2024.109430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Intestinal malrotation is a congenital abnormality predominantly diagnosed in children, with only a few cases reported in adults. Patients may be incidentally identified during unrelated surgical procedures or postmortem examinations. It is crucial to promptly recognize this condition to prevent severe complications such as bowel ischemia and potential fatality. CASE PRESENTATION A 40-year-old male presented to the Emergency Department after a child jumped on his abdomen with complaints of acute left upper quadrant abdominal pain progressing to be generalized. Examination showed pallor, abdominal tenderness without guarding or rigidity, and intact bowel sounds. Preoperative diagnostic tools revealed intestinal malrotation confirmed during the laparotomy, prompting the performance of Ladd's procedure to address the malrotation. CLINICAL DISCUSSION Disruption in the normal embryological development of bowel is the cause of intestinal malrotation. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated. CONCLUSION Intestinal malrotation is rare in adults and often found incidentally during evaluation for unrelated medical conditions. Timely identification and surgical intervention usually result in positive outcomes. Our case underscores the incidental discovery of malrotation during the evaluation of blunt abdominal trauma, treated with Ladd's procedure. This is particularly significant due to geographical constraints associated with the patient's rural origin, as untreated malrotation could lead to complications in future occurrences.
Collapse
Affiliation(s)
- Shishir Devkota
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prajjwol Luitel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | - Sujan Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Nischal Neupane
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Santosh Dev
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prasan Bir Singh Kansakar
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| |
Collapse
|
3
|
Grzymkowski JK, Chiu YC, Jima DD, Wyatt BH, Jayachandran S, Stutts WL, Nascone-Yoder NM. Developmental regulation of cellular metabolism is required for intestinal elongation and rotation. Development 2024; 151:dev202020. [PMID: 38369735 PMCID: PMC10911142 DOI: 10.1242/dev.202020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/15/2024] [Indexed: 02/20/2024]
Abstract
Malrotation of the intestine is a prevalent birth anomaly, the etiology of which remains poorly understood. Here, we show that late-stage exposure of Xenopus embryos to atrazine, a widely used herbicide that targets electron transport chain (ETC) reactions, elicits intestinal malrotation at high frequency. Interestingly, atrazine specifically inhibits the cellular morphogenetic events required for gut tube elongation, including cell rearrangement, differentiation and proliferation; insufficient gut lengthening consequently reorients the direction of intestine rotation. Transcriptome analyses of atrazine-exposed intestines reveal misexpression of genes associated with glycolysis and oxidative stress, and metabolomics shows that atrazine depletes key glycolytic and tricarboxylic acid cycle metabolites. Moreover, cellular bioenergetics assays indicate that atrazine blocks a crucial developmental transition from glycolytic ATP production toward oxidative phosphorylation. Atrazine-induced defects are phenocopied by rotenone, a known ETC Complex I inhibitor, accompanied by elevated reactive oxygen species, and rescued by antioxidant supplementation, suggesting that malrotation may be at least partly attributable to redox imbalance. These studies reveal roles for metabolism in gut morphogenesis and implicate defective gut tube elongation and/or metabolic perturbations in the etiology of intestinal malrotation.
Collapse
Affiliation(s)
- Julia K. Grzymkowski
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
| | - Yu-Chun Chiu
- Molecular Education, Technology and Research Innovation Center (METRIC), Raleigh, NC 27695, USA
| | - Dereje D. Jima
- Center for Human Health and the Environment, North Carolina State University, Raleigh, North Carolina 27695, USA
- Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27607, USA
| | - Brent H. Wyatt
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
| | - Sudhish Jayachandran
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
| | - Whitney L. Stutts
- Molecular Education, Technology and Research Innovation Center (METRIC), Raleigh, NC 27695, USA
- Department of Molecular and Structural Biochemistry, North Carolina State University, Raleigh, NC 27695, USA
| | - Nanette M. Nascone-Yoder
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
| |
Collapse
|
4
|
Brezler E, Sico R, Seifarth FG. Midgut volvulus in a pediatric patient with chronic constipation, congenital intestinal malrotation and internal transmesocolic hernia. BMJ Case Rep 2023; 16:e254425. [PMID: 37437960 PMCID: PMC10347442 DOI: 10.1136/bcr-2022-254425] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
Congenital intestinal malrotation occurs in 1 of 500 newborns and can predispose patients to intestinal volvulus and internal herniation, putting patients at risk for intestinal ischaemia. A male patient in early childhood with a history of severe constipation presented with acute abdominal pain, progressing rapidly to compensated shock. CT scan was suspicious for small bowel ischaemia and superior mesenteric artery compression. He underwent emergency exploratory laparotomy. Intraoperative findings were significant for partial intestinal malrotation with mobile ascending colon and high-riding caecum, and internal herniation with midgut volvulus of the ascending colon through a mesenteric defect in the proximal transverse colon. Derotation of the volvulus, reduction of the internal hernia, resection of necrotic segments of the bowel and a modified Ladd's procedure were performed. Postoperatively, the patient is total parenteral nutrition (TPN) dependent due to short bowel syndrome. A high index of suspicion with prompt imaging is paramount for paediatric patients with symptoms indicating intestinal obstruction.
Collapse
Affiliation(s)
- Emily Brezler
- Department of Surgery, Division of Pediatric Surgery, WVU Medicine Children's Hospital, Morgantown, West Virginia, USA
| | - Rita Sico
- Pediatric Radiology, WVU Medicine Children's Hospital, Morgantown, West Virginia, USA
| | - Federico G Seifarth
- Department of Surgery, Division of Pediatric Surgery, WVU Medicine Children's Hospital, Morgantown, West Virginia, USA
| |
Collapse
|
5
|
Al Smady MN, Hendi SB, AlJeboury S, Al Mazrooei H, Naji H. Appendectomy as part of Ladd's procedure: a systematic review and survey analysis. Pediatr Surg Int 2023; 39:164. [PMID: 37010655 PMCID: PMC10070202 DOI: 10.1007/s00383-023-05437-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Ladd's Procedure has been the surgical intervention of choice in the management of congenital intestinal malrotation for the past century. Historically, the procedure included performing an appendectomy to prevent future misdiagnosis of appendicitis, since the location of the appendix will be shifted to the left side of the abdomen. This study consists of two parts. A review of the available literature on appendectomy as part of Ladd's procedure and then a survey sent to pediatric surgeons about their approach (to remove the appendix or not) while performing a Ladd's procedure and the clinical reasoning behind their approach. METHODS The study consists of 2 parts: (1) a systematic review was performed to extract articles that fulfill the inclusion criteria; (2) a short online survey was designed and sent by email to 168 pediatric surgeons. The questions in the survey were centered on whether a surgeon performs an appendectomy as part of the Ladd's procedure or not, as well as their reasoning behind either choice. RESULTS The literature search yielded five articles, the data from the available literature are inconsistent with performing appendectomy as part of Ladd's procedure. The challenge of leaving the appendix in place has been briefly described with minimal to no focus on the clinical reasoning. The survey demonstrated that 102 responses were received (60% response rate). Ninety pediatric surgeons stated performing an appendectomy as part of the procedure (88%). Only 12% of pediatric surgeons are not performing appendectomy during Ladd's procedure. CONCLUSION It is difficult to implement a modification in a successful procedure like Ladd's procedure. The majority of pediatric surgeons perform an appendectomy as part of its original description. This study has identified gaps in the literature pertaining to analyze the outcomes of performing Ladd's procedure without an appendectomy which should be explored in future research.
Collapse
Affiliation(s)
| | - Salama Bin Hendi
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Sarah AlJeboury
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Hessa Al Mazrooei
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Hussein Naji
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE.
- Mediclinic Parkview Hospital, Dubai, UAE.
| |
Collapse
|
6
|
Takimoto A, Amano H, Sumida W, Shirota C, Yokota K, Makita S, Okamoto M, Ogata S, Takada S, Nakagawa Y, Kato D, Goda Y, Hinoki A, Uchida H. Laparoscopic Duodenal-Caudal Detachment Method: Early Experience of a Novel Technique for Malrotation with Volvulus in Neonates. J Laparoendosc Adv Surg Tech A 2023; 33:220-225. [PMID: 36383112 DOI: 10.1089/lap.2022.0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: A laparoscopic approach for malrotation is feasible and safe in hemodynamically stable neonates without intestinal necrosis; however, volvulus is associated with recurrence and conversion. We developed a novel approach using a laparoscopic duodenal-caudal detachment method to perform the Ladd procedure for neonates with volvulus under the limited view of laparoscopy. This study presents the results, effectiveness, and details of the method. Materials and Methods: In the laparoscopic duodenal-caudal detachment method, we first detached the adhesions around the duodenum, including the Ladd's band. After the adhesions were completely removed, the duodenum was freely drawn caudally, leading to the release of torsion. We retrospectively reviewed the medical records of patients who underwent surgery for malrotation of the volvulus at 30 days of age between January 2014 and September 2021. Results: Seven neonates underwent the laparoscopic duodenal-caudal detachment method and 13 underwent the open Ladd procedure. The new technique was performed in all 7 patients, and there were no conversions or recurrences. The operation time was significantly longer in the laparoscopic procedure group (55 minutes versus 111 minutes; P < .01). Conclusions: Our detorsion method, involving an initial incision of the Ladd's band, is safe and effective for neonates and may lead to an improvement in the conversion rates.
Collapse
Affiliation(s)
- Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Seiya Ogata
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Youichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Yosuke Goda
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, , Showa, Nagoya, Japan
| |
Collapse
|
7
|
Impact of gastrointestinal comorbidities in patients with right and left atrial isomerism. Cardiol Young 2022; 32:1053-1060. [PMID: 34470692 DOI: 10.1017/s1047951121003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIM Heterotaxy syndrome, being right atrial isomerism (RAI) or left atrial isomerism (LAI), often presents with Congenital Heart Disease (CHD). Intestinal abnormalities, including malrotation are common. We assessed the spectrum of gut abnormalities and their impact on medium-term outcome in a cohort of patients with fetal and postnatal diagnoses of heterotaxy syndrome. METHODS We reviewed the cardiology records of heterotaxy syndrome patients from two centres, regarding the presence of CHD, time for cardiac intervention, presence of gastrointestinal abnormalities, and type/time of surgery. A questionnaire about gastrointestinal status was sent to patients <18 years old. Kaplan-Meier curves were derived for survival data and freedom from intervention. RESULTS Data were included for 182 patients (49 RAI and 133 LAI) of 247 identified. Questionnaires were sent to 77 families and 47 replied. CHD was present in all RAI and 61.7% of LAI cases. Thirty-eight patients had abdominal surgery (20.9%), similar for RAI and LAI (20.4% versus 21%, p> 0.99): Ladd procedure in 17 (44.7%), non-Ladd in 12 (31.5%), and both procedures in 9 (23.7%). Ten-year freedom from Ladd procedure for all was 86% for the whole cohort (RAI = 87%; LAI = 85%, p = 0.98). Freedom from any gastrointestinal surgery at 10 years was 79% for the whole cohort (RAI = 77%; LAI = 80%, p = 0.54). Ten-year freedom from cardiac surgery was 31% for the whole cohort (RAI = 6%; LAI = 43%, p < 0.0001). CONCLUSIONS In our cohort, one in five patients required abdominal surgery, mostly in their first year of life, similar for RAI and LAI. Between 1 and 10 years of follow-up, the impact of gastrointestinal abnormalities on outcome was minimal. Medium term survival was related to CHD.
Collapse
|
8
|
Sonographic diagnosis of malrotation: it's complicated - counterpoint. Pediatr Radiol 2022; 52:723-725. [PMID: 34389875 DOI: 10.1007/s00247-021-05163-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/05/2021] [Accepted: 07/26/2021] [Indexed: 01/30/2023]
Abstract
Focused abdominal sonography (US) has been suggested as a first-line modality for the diagnosis of malrotation and volvulus in newborns. In this paper, the author reviews the strengths and weaknesses of US in the diagnosis and exclusion of malrotation and volvulus. The author reviews published implementation programs for using US in both conditions and describes the anatomical variations that limit the utility of US depiction of a retromesenteric duodenum in the exclusion of malrotation.
Collapse
|
9
|
Greenbaum R, Koyama A. Malrotation With Midgut Volvulus in an Adolescent Male. Pediatr Emerg Care 2022; 38:e1082-e1084. [PMID: 35226634 DOI: 10.1097/pec.0000000000002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Malrotation and midgut volvulus are conditions commonly described in infants, typically diagnosed within the first month of life. We present an unusual occurrence of high-grade obstruction because of malrotation and volvulus in an adolescent male. His symptoms at presentation, abdominal pain and vomiting, were similar to previous episodes in which he had been diagnosed with constipation or viral gastroenteritis and discharged home. His main criteria for admission for this occurrence were related to his degree of dehydration.
Collapse
Affiliation(s)
| | - Atsuko Koyama
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
10
|
The diagnostic accuracy of ultrasound and upper gastrointestinal contrast studies for locating atresia/stenosis and intestinal malrotation and detecting annular pancreas in pediatric patients with duodenal atresia/stenosis. J Med Ultrason (2001) 2022; 49:299-309. [PMID: 34988762 DOI: 10.1007/s10396-021-01176-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to evaluate the diagnostic performance of ultrasound to locate atresia/stenosis and other abdominal anomalies in pediatric patients with duodenal atresia/stenosis, including intestinal malrotation and annular pancreas. METHODS We classified 36 retrospective cases of duodenal atresia/stenosis based on intestinal malrotation status, and evaluated the diagnostic performance of ultrasound/upper gastrointestinal contrast studies to locate atresia/stenosis and intestinal malrotation, as well as ultrasound for detecting additional anomalies such as annular pancreas. The incidence of annular pancreas was compared between groups using Fisher's exact test. RESULTS Atresia/stenosis was correctly located by ultrasound in 33 (91.7%) cases and by upper gastrointestinal contrast study in 36 (100%) cases. Of the eight cases with intestinal malrotation, five and two were correctly diagnosed by ultrasound and upper gastrointestinal contrast study, respectively. Ultrasound correctly diagnosed annular pancreas in 6/14 cases. The incidence of annular pancreas was significantly different between the groups (present/absent in groups with vs. without intestinal malrotation: 6/2 vs. 8/20, P = 0.036). CONCLUSIONS Ultrasound has a relatively high capability in locating atresia/stenosis. However, some cases are misdiagnosed. In clinical practice, upper gastrointestinal contrast studies should be used complementarily during diagnosis. Additional anomalies may not be detected by preoperative examinations; therefore, surgeons should carefully evaluate for additional anomalies during surgery, especially coexisting intestinal malrotation and annular pancreas.
Collapse
|
11
|
Al Laham O, Albrijawy R, Ahmad I, Atia F, Shaheen J, Alaa Aldeen B. A distinctive case of congenital midgut malrotation with volvulus in an adolescent female managed by Ladd's procedure - A case report. Int J Surg Case Rep 2022; 90:106752. [PMID: 34999472 PMCID: PMC8749212 DOI: 10.1016/j.ijscr.2021.106752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction and importance Midgut Malrotation (MM) is a potentially fatal and rare congenital anomaly that results from an incomplete rotation of the bowel 270 degrees around the Superior Mesenteric Axis. Newborns are the most affected age group, nevertheless, adult malrotation can manifest, but in a much rarer incidence rate. Clinical awareness must be present when faced with a surgical abdomen in an adolescent patient because this pathology can have several misleading signs and symptoms which may eclipse the true preoperative diagnosis and masquerade as another, and this could result in implementing a different therapeutic approach. Swift clinical informed judgments must be made and acted upon to limit the morbidity and mortality resultant from this pathology. Case presentation We present the case of a 15-year-old female, who was brought to our Emergency Department (ED) with a 5-day-history of biliary emesis which evolved into obstipation with continuous and excruciating abdominal pain. Computed Tomography (CT) scan indicated gastric and duodenal dilation in addition to a “Whirlpool sign”. Exploratory laparotomy was done, and a Ladd's procedure was performed. Clinical discussion We treated our patient by performing Ladd's procedure and adhesiolysis. Diagnosis is conventionally established pre-/intraoperatively based on radiological imaging and clinical suspicion. Therapeutic methods for this pathology are primarily surgical in nature. Conclusion Midgut Malrotation is a rare entity, thus, it is crucial to further study this type of clinical presentation and keep it in mind to be able to make an accurate diagnosis to reach the optimal outcome for patients who present with acute surgical abdomen. MM is a potentially fatal and rare congenital anomaly of the Gastrointestinal tract comprising 0.2% of live births. Most cases are diagnosed within the first year of neonatal life. Rarely, a case is diagnosed in the adolescent population. Symptoms are non-specific and this warrants high clinical suspicion when presented with a case of acute surgical abdomen. There are three major types of Midgut Malrotation according to the established Stringer classification. Surgery is the mainstream treatment modality and Ladd's procedure and remains the gold standard for treatment of MM.
Collapse
Affiliation(s)
- Omar Al Laham
- Department of Surgery, Al-Mouwasat University Hospital & Al Assad University Hospital, Syria; Al-Mouwasat University Hospital, Mazzah, Damascus, Syria; Al Assad University Hospital, April 17(th) St. Kafar Sousah, Damascus, Syria.
| | - Reham Albrijawy
- Department of Surgery, Al-Mouwasat University Hospital & Al Assad University Hospital, Syria; Al-Mouwasat University Hospital, Mazzah, Damascus, Syria; Al Assad University Hospital, April 17(th) St. Kafar Sousah, Damascus, Syria.
| | - Issa Ahmad
- Department of Surgery, Al-Mouwasat University Hospital & Al Assad University Hospital, Syria; Al-Mouwasat University Hospital, Mazzah, Damascus, Syria; Al Assad University Hospital, April 17(th) St. Kafar Sousah, Damascus, Syria.
| | - Fareed Atia
- Department of Surgery, Al-Mouwasat University Hospital & Al Assad University Hospital, Syria; Al-Mouwasat University Hospital, Mazzah, Damascus, Syria; Al Assad University Hospital, April 17(th) St. Kafar Sousah, Damascus, Syria.
| | - Jack Shaheen
- Department of Surgery, Al-Mouwasat University Hospital & Al Assad University Hospital, Syria; Al-Mouwasat University Hospital, Mazzah, Damascus, Syria; Al Assad University Hospital, April 17(th) St. Kafar Sousah, Damascus, Syria.
| | | |
Collapse
|
12
|
Revathi G, Singh BK, Rathore YS, Chumber S. Laparoscopic management of type VI choledochal cyst with common bile duct stone: report of a case and review of literature. BMJ Case Rep 2021; 14:e244393. [PMID: 34645627 PMCID: PMC8515435 DOI: 10.1136/bcr-2021-244393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 11/03/2022] Open
Abstract
A young adult male presented with biliary colic and intermittent jaundice for 1 year. Abdomen findings were unremarkable. Routine investigations revealed a raised total bilirubin. On abdominal ultrasonography, common bile duct (CBD) dilatation with multiple stones was noted. On further imaging with magnetic resonance cholangiopancreatography, type I choledochal cyst (CDC) was suspected. A laparoscopic approach was planned. Intraoperatively, dilatation of cystic duct was noted which constitute type VI CDC. Partial malrotation of the gut and accessory right hepatic artery were also noted as incidental finding. Laparoscopic cholecystectomy with CBD exploration and removal of stones, biliary stent placement, cystic duct cyst excision and primary repair of CBD was done. Postoperatively, the patient improved symptomatically with a fall in bilirubin to normal range. We are describing the laparoscopic management of a rare case of type IV CDC which was diagnosed intraoperatively.
Collapse
Affiliation(s)
- G Revathi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Brijesh Kumar Singh
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
13
|
Abu-Elmagd K, Mazariegos G, Armanyous S, Parekh N, ElSherif A, Khanna A, Kosmach-Park B, D'Amico G, Fujiki M, Osman M, Scalish M, Pruchnicki A, Newhouse E, Abdelshafy AA, Remer E, Costa G, Walsh RM. Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure. Ann Surg 2021; 274:581-596. [PMID: 34506313 PMCID: PMC8428856 DOI: 10.1097/sla.0000000000005072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established. METHODS Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients. RESULTS The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001). CONCLUSIONS Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.
Collapse
Affiliation(s)
| | - George Mazariegos
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Neha Parekh
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Ajai Khanna
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Beverly Kosmach-Park
- University of Pittsburgh Medical Center and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | - Erick Remer
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | |
Collapse
|
14
|
Hunt TM, Thacker PG. Sonographic Detection of Congenital Intestinal Malrotation: A Case Report. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/87564793211037612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intestinal malrotation is a rare fetal anomaly resulting from the failure of midgut rotation and fixation. Sonography is typically the first modality of choice for assessing pediatric pathology due to its high sensitivity, portability, real-time imaging capability, and non-ionizing technique; however, its role in diagnosing small bowel rotational anomalies remains limited and controversial. Fluoroscopic upper gastrointestinal imaging (UGI) is the primary diagnostic examination at most institutions. However, even on UGI, imaging findings may be equivocal. In such cases, sonography may provide additional information at facilities where it is not used as a primary diagnostic tool. This case report represents the first reported case showing how patient position is important as the typical vascular sonographic features of rotation were normal in one position but abnormal in another. In addition, this case shows how congenital intestinal malrotation was decisively diagnosed using sonographic imaging.
Collapse
|
15
|
Enomoto N, Yamada K, Kato D, Yagi S, Wake H, Nohara K, Takemura N, Kiyomatsu T, Kokudo N. Right-sided Bochdalek hernia in an adult with hepatic malformation and intestinal malrotation. Surg Case Rep 2021; 7:169. [PMID: 34273029 PMCID: PMC8286215 DOI: 10.1186/s40792-021-01232-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background Bochdalek hernia is a common congenital diaphragmatic defect that usually manifests with cardiopulmonary insufficiency in neonates. It is very rare in adults, and symptomatic cases are mostly left-sided. Diaphragmatic defects generally warrant immediate surgical intervention to reduce the risk of incarceration or strangulation of the displaced viscera. Case presentation A 47-year-old woman presented with dyspnea on exertion. Computed tomography revealed that a large part of the intestinal loop with superior mesenteric vessels and the right kidney were displaced into the right thoracic cavity. Preoperative three-dimensional (3D) simulation software visualized detailed anatomy of displaced viscera and the precise location and size of the diaphragmatic defect. She underwent elective surgery after concomitant pulmonary hypertension was stabilized preoperatively. The laparotomic approach was adopted. Malformation of the liver and the presence of intestinal malrotation were confirmed during the operation. The distal part of the duodenum, jejunum, ileum, colon, and right kidney were reduced into the abdominal cavity consecutively. A large-sized oval defect was closed with monofilament polypropylene mesh. No complications occurred postoperatively. Conclusion Symptomatic right-sided Bochdalek hernia in adults is exceedingly rare and is frequently accompanied by various visceral anomalies. Accurate diagnosis and appropriate surgical repair are crucial to prevent possible incarceration or strangulation. The preoperative 3D simulation provided comprehensive information on anatomy and concomitant anomalies and helped surgeons plan the operation meticulously and perform procedures safely.
Collapse
Affiliation(s)
- Naoki Enomoto
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kazuhiko Yamada
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Daiki Kato
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Shusuke Yagi
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Hitomi Wake
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kyoko Nohara
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norihiro Kokudo
- Department of Surgery, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| |
Collapse
|
16
|
Neville JJ, Gallagher J, Mitra A, Sheth H. Adult Presentations of Congenital Midgut Malrotation: A Systematic Review. World J Surg 2021; 44:1771-1778. [PMID: 32030442 DOI: 10.1007/s00268-020-05403-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jonathan J Neville
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK. .,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK.
| | - Jack Gallagher
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK.,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK
| | - Anuja Mitra
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK.,Imperial College Healthcare NHS Trust, Paddington, London, W2 1NY, UK
| | - Hemant Sheth
- Ealing Hospital, London North West University Healthcare NHS Trust, Uxbridge Road, London, UB1 3HW, UK
| |
Collapse
|
17
|
Son J, Lee S, Kim W, Jung SM, Jeon TY, Yoo SY, Kim JH, Seo JM. Abnormal Orientation of the Superior Mesenteric Vessels Detected in Asymptomatic Infants: What Is Its Destiny? Front Pediatr 2021; 9:665448. [PMID: 34178885 PMCID: PMC8226012 DOI: 10.3389/fped.2021.665448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasonography (USG) has been described as an alternative diagnostic tool for malrotation that evaluates the orientation of the superior mesenteric vessels. However, literature concerning the management of patients who do not have abdominal symptoms is limited. We aimed to review the clinical course of infants showing abnormal orientation of the superior mesenteric vessels on USG who were asymptomatic at the time of diagnosis. Methods: Seventy asymptomatic infants with abnormal orientation of the superior mesenteric vessels in a single center between 2014 and 2018 were retrospectively analyzed. Results: The 70 patients, 21 underwent upper gastrointestinal series (UGIS) and 11 underwent abdominal surgery for other surgical conditions. Among the 32 (45.7%) patients who underwent UGIS or abdominal surgery, 11 were proven to have malrotation. Of the 38 (54.3%) patients who did not undergo UGIS or abdominal surgery, six patients were too unstable to undergo UGIS, five died due to cardiac complications, and the remaining patient developed midgut volvulus and died 3 days after emergency surgery. The remaining 32 patients who did not undergo UGIS or abdominal surgery were discharged without additional tests, and all were asymptomatic until their last follow-up. In the multivariate analysis, history of heart surgery and the presence of more than three anomalies were significantly associated with malrotation. Conclusion: A significant number of malrotation were diagnosed in asymptomatic infants with abnormal orientation of the superior mesenteric vessels on USG. Infants with major cardiac or multiple anomalies need special attention and should undergo UGIS in a promptly manner to confirm malrotation.
Collapse
Affiliation(s)
- Joonhyuk Son
- Department of Pediatric Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Min Jung
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So-Young Yoo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
18
|
Abstract
BACKGROUND Laparoscopic approach for malrotation has become more popular for neonates and in cases with volvulus, but its safety and efficacy remains controversial. This study reviewed laparoscopy outcomes in neonate/infant malrotation. METHODS Medline/PubMed and Lilacs databases were reviewed. Data from studies published in English/Spanish between 1995 and 2019 were collected. Results are presented as percentages and means/medians; logistic regression was used to study possible associations. RESULTS Nineteen papers offered 99 neonates/infants with median age and weight of 10.5 days and 3.5 kg, respectively. Ladd's procedure was performed in 95 (96%) patients and bands' division in 4 (4%); appendectomy was not included in 16 (16.2%) patients, and cecopexy was not performed in all cases. Volvulus was reported in 39 (39.4%) patients. There were 11 conversions (11.1%) and 10 recurrences of symptoms (10.1%) that required reintervention. An association was found between volvulus and recurrence (P = .05) and the need for conversion (P < .01). There were 10 (10.1%) minor complications and no mortality. The median follow-up was 10 months. DISCUSSION Laparoscopic approach to malrotation is feasible and safe in hemodynamically stable neonates/infants without intestinal necrosis and is associated with 11% conversion rate and 10% reinterventions. The presence of volvulus is associated with recurrence and conversion. Laparoscopic Ladd's procedure with appendectomy and without cecopexy is the commonly practiced approach that is associated with minor complications.
Collapse
Affiliation(s)
- Karina M da Costa
- 9762 Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK.,42487 Division of Pediatric Surgery, Department of Pediatrics, Regional University Hospital of Maringá, State University of Maringá, Maringá, Brazil
| | - Amulya K Saxena
- 9762 Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK
| |
Collapse
|
19
|
Rodríguez Vargas CM, Bayter Mendoza EF, Baquero García RL. Hernia paracecal, reto diagnóstico y quirúrgico: reporte de caso y revisión de la literatura. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La hernia paracecal es una entidad rara que corresponde al 13 % de todas las hernias internas. Aunque algunas pueden ser adquiridas, la mayoría son congénitas y se originan en los recesos creados durante la adherencia y fusión de los repliegues peritoneales alrededor de la región ileocecal.
Caso clínico. Se trata de un hombre de 42 años de edad a quien se le diagnosticó una apendicitis aguda. La intervención quirúrgica se inició con una incisión para apendicectomía localizada; no obstante, por los hallazgos intraoperatorios, se decidió la conversión a laparotomía y se produjo el hallazgo incidental de una hernia paracecal.
Resultados. El paciente fue hospitalizado y, en el quinto día postoperatorio, presentó obstrucción intestinal por lo cual fue intervenido nuevamente; se encontró escaso líquido de reacción peritoneal y adherencias. Se le dio el egreso hospitalario cuatro días después de su último procedimiento quirúrgico y continuaba asintomático hasta su segundo control.
Discusión. Las hernias paracecales son hernias internas que se describen como la protrusión de una víscera hueca por una apertura mesentérica o peritoneal. Sus manifestaciones clínicas son variadas y se puede presentar sin síntomas, con dolor abdominal localizado o hasta con obstrucción intestinal. El tratamiento quirúrgico se basa en liberar y examinar el segmento intestinal herniado y, de requerirse, proceder a la resección con anastomosis; se debe resecar el saco herniario cuando sea evidente, valorar los vasos mesentéricos y cerrar el defecto herniario.
Se trata de una enfermedad poco común y es importante conocer su manejo con la finalidad de evitar complicaciones, ya que continúa siendo un reto diagnóstico para el cirujano.
Collapse
|
20
|
Alventosa Mateu C, Núñez Martínez PC, Castillo López GA, Pascual Romero A. Is there an association between adult symptomatic intestinal malrotation and small intestinal bacterial overgrowth? GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:637-638. [PMID: 32674876 DOI: 10.1016/j.gastrohep.2020.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Carlos Alventosa Mateu
- Servicio de Medicina Digestiva, Hospital de Dénia Marina Salud, Dénia, Alicante, España.
| | | | | | - Andrea Pascual Romero
- Servicio de Medicina Digestiva, Hospital de Dénia Marina Salud, Dénia, Alicante, España
| |
Collapse
|
21
|
Gupta R, Gupta A. Duodenal atresia type III showing distal bowel gas and atypical malrotation in association with gastric and bile duct duplications. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_47_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
22
|
Neville JJ, Sharma E, Al-Muzrakchi A, Sheth H. Congenital intestinal malrotation presenting in octogenarians: a report of two cases. Ann R Coll Surg Engl 2019; 102:e12-e14. [PMID: 31859525 DOI: 10.1308/rcsann.2019.0169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Malrotation is part of a spectrum of small and large bowel positional and fixational abnormalities caused by the failure of the fetal intestine to complete a 270-degree rotation around the superior mesenteric artery axis. Rarely, it presents in the adult as a cause of acute small bowel obstruction. Chronic symptoms of malrotation in adults are subtle, and include intermittent abdominal pain, nausea and vomiting. We present two cases of malrotation in octogenarian men presenting acutely with small bowel obstruction. Both patients were treated with emergency surgery. In one case the chronic symptoms resolved postoperatively. Malrotation and midgut volvulus should be considered as a rare differential diagnosis for small bowel obstruction in adults. Suspicions should be increased when there is a history of recurrent presentations with similar symptoms.
Collapse
Affiliation(s)
- J J Neville
- Imperial College Healthcare NHS Trust, London, UK.,Ealing Hospital, London North West University Healthcare NHS Trust, Southall, London, UK
| | - E Sharma
- Imperial College Healthcare NHS Trust, London, UK.,Ealing Hospital, London North West University Healthcare NHS Trust, Southall, London, UK
| | - A Al-Muzrakchi
- Ealing Hospital, London North West University Healthcare NHS Trust, Southall, London, UK
| | - H Sheth
- Ealing Hospital, London North West University Healthcare NHS Trust, Southall, London, UK
| |
Collapse
|
23
|
Colvin D, Bourke T, Thompson A, Dick AC. Should children with non-bilious vomiting and malrotation undergo a Ladd's procedure or be managed conservatively? Arch Dis Child 2019; 104:1116-1118. [PMID: 31391154 DOI: 10.1136/archdischild-2019-317672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 11/03/2022]
Affiliation(s)
- David Colvin
- Department of Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Thomas Bourke
- Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK.,Department of Medical Education, Queen's University of Belfast: Faculty of Medicine, Health and Life Sciences, Belfast, UK
| | - Andrew Thompson
- Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Alistair C Dick
- Department of Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, UK
| |
Collapse
|
24
|
Midgut malrotation complicated by small bowel obstruction in an 80-year-old woman: A case report. Int J Surg Case Rep 2019; 63:89-93. [PMID: 31574456 PMCID: PMC6796602 DOI: 10.1016/j.ijscr.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/23/2019] [Accepted: 09/08/2019] [Indexed: 12/19/2022] Open
Abstract
Intestinal malrotation results from anomalies in embryological midgut rotation. Malrotation usually presents early in life, with rare cases reported in adulthood. Ladd procedure remains the mainstay of definitive treatment. Radiologic findings have a role in early detection and correction of malrotation.
Introduction Midgut malrotation results from abnormalities in the 270-degree counterclockwise rotation of the midgut around the axis of the superior mesenteric artery during embryological development, and classically presents early in life with symptoms of intestinal obstruction. Nevertheless, adult cases have occasionally been reported. Presentation of case An 80-year-old female with no surgical history was brought to our emergency department for acutely altered mental status. On exam, her abdomen was distended and diffusely tender to palpation. Computed tomography (CT) scan of the abdomen and pelvis showed a dilated loop of jejunum with evidence of mesenteric twist concerning for closed-loop small bowel obstruction. The patient was taken for exploratory laparotomy and was found to have Ladd bands and other findings suggestive of intestinal malrotation. A Ladd procedure was performed and the patient remained under observation. She experienced intermittent abdominal distension and bilious nasogastric tube output, but subsequent CT scans revealed no evidence of obstruction. She was discharged following clinical improvement and ability to tolerate a diet. Discussion Malrotation of the small bowel exists on a spectrum depending on the embryologic stage during which anomalous rotation occurs. Classic findings on CT imaging (including abnormal mesenteric vasculature, right-sided duodenojejunal junction, whirlpool signs, and left-sided ascending colon) can provide clues to the existence of malrotation. Conclusion Although malrotation is rare in adults, clinical and radiologic findings play an important role in the correct diagnosis of adult malrotation for appropriate and timely intervention.
Collapse
|
25
|
Salehi Karlslätt K, Pettersson M, Jäntti N, Szafranski P, Wester T, Husberg B, Ullberg U, Stankiewicz P, Nordgren A, Lundin J, Lindstrand A, Nordenskjöld A. Rare copy number variants contribute pathogenic alleles in patients with intestinal malrotation. Mol Genet Genomic Med 2019; 7:e549. [PMID: 30632303 PMCID: PMC6418355 DOI: 10.1002/mgg3.549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/05/2018] [Accepted: 12/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intestinal malrotation is a potentially life-threatening congenital anomaly due to the risk of developing midgut volvulus. The reported incidence is 0.2%-1% and both apparently hereditary and sporadic cases have been reported. Intestinal malrotation is associated with a few syndromes with known genotype but the genetic contribution in isolated intestinal malrotation has not yet been reported. Rare copy number variants (CNVs) have been implicated in many congenital anomalies, and hence we sought to investigate the potential contribution of rare CNVs in intestinal malrotation. METHODS Analysis of array comparative genomic hybridization (aCGH) data from 47 patients with symptomatic intestinal malrotation was performed. RESULTS We identified six rare CNVs in five patients. Five CNVs involved syndrome loci: 7q11.23 microduplication, 16p13.11 microduplication, 18q terminal deletion, HDAC8 (Cornelia de Lange syndrome type 5 and FOXF1) as well as one intragenic deletion in GALNT14, not previously implicated in human disease. CONCLUSION In the present study, we identified rare CNVs contributing pathogenic or potentially pathogenic alleles in five patients with syndromic intestinal malrotation, suggesting that CNV screening is indicated in intestinal malrotation with associated malformations or neurological involvements. In addition, we identified intestinal malrotation in two known syndromes (Cornelia de Lange type 5 and 18q terminal deletion syndrome) that has not previously been associated with gastrointestinal malformations.
Collapse
Affiliation(s)
- Karin Salehi Karlslätt
- Department of Women's and Children's Health and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Pettersson
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nina Jäntti
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Przemyslaw Szafranski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Britt Husberg
- Department of General Surgery, Ersta Hospital, Stockholm, Sweden
| | - Ulla Ullberg
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Pawel Stankiewicz
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Ann Nordgren
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Lundin
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Lindstrand
- Department of Molecular Medicine and Surgery and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
26
|
Hmadeh H, Saliba C, Raka M, Farhat HA, Dabbous A, Diab S, Abbas L, Wehbe A. An Unusual Case of Intestinal Malrotation Causing Duodenal Obstruction by a Looped Appendix. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1362-1365. [PMID: 30429450 PMCID: PMC6250999 DOI: 10.12659/ajcr.913039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Male, 30 Final Diagnosis: Duodenal obstruction caused by a looped appendix due to intestinal malrotation Symptoms: Post postprandial vomiting Medication: — Clinical Procedure: Improved after unwinding of the looped appendix and subsequent appendectomy Specialty: Surgery
Collapse
Affiliation(s)
- Hussein Hmadeh
- Department of General Surgery, Sahel General Hospital, Beirut, Lebanon
| | - Christian Saliba
- Department of General Surgery, Lebanese American University Medical Center/Beirut General University Hospital/Mount Lebanon Hospital, Beirut, Lebanon
| | - Mohamad Raka
- Department of General Surgery, Sahel General Hospital, Beirut, Lebanon
| | | | - Ali Dabbous
- Department of General Surgery, Sahel General Hospital, Beirut, Lebanon
| | - Samer Diab
- Department of General Surgery, Lebanese American University Medical Center/Beirut General University Hospital/Mount Lebanon Hospital, Beirut, Lebanon
| | - Layan Abbas
- Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Ali Wehbe
- Department of General Surgery, Mount Lebanon Hospital, Beirut, Lebanon
| |
Collapse
|
27
|
Chen JH. Left-sided cecal diverticulitis associated with midgut malrotation. Tzu Chi Med J 2018; 30:47-50. [PMID: 29643718 PMCID: PMC5883838 DOI: 10.4103/tcmj.tcmj_190_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Malrotation of the midgut is generally considered as a pediatric pathology with the majority of patients presenting in childhood. The diagnosis is rare in adults, which sometimes leads to delay in diagnosis and treatment. An index of suspicion is therefore required when dealing with patients of any age group with abdominal symptoms. We present a case of a 26-year-old male who presented with left lower abdominal pain with preoperative computed tomography showing suspected left-sided appendicitis associated with midgut malrotation. The duodenum, small bowel, and cecum were abnormally located, with the presence of a thickened and inflamed appendix with fecalith images. The patient underwent an emergency laparotomy, and ruptured cecal diverticulitis with abscess formation was confirmed. We performed a cecectomy, and the patient did not have an uneventful postoperative recovery. A review of the literature is presented to highlight the rarity of midgut malrotation and the controversies surrounding its surgical management in the adult population with ruptured left-sided cecal diverticulitis.
Collapse
Affiliation(s)
- Jia-Hui Chen
- Division of General Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,Graduate Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| |
Collapse
|
28
|
Neonatal Bowel Disorders: Practical Imaging Algorithm for Trainees and General Radiologists. AJR Am J Roentgenol 2018. [PMID: 29528714 DOI: 10.2214/ajr.17.19378] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Neonatal bowel disorders require prompt and accurate diagnosis to avoid potential morbidity and mortality. Symptoms such as feeding intolerance, emesis, or failure to pass meconium may prompt a radiologic evaluation. CONCLUSION We discuss the most common neonatal bowel disorders and present a practical imaging algorithm for trainees and general radiologists.
Collapse
|
29
|
Amini Khoiy K, Abdulhai S, Glenn IC, Ponsky TA, Amini R. Anisotropic and nonlinear biaxial mechanical response of porcine small bowel mesentery. J Mech Behav Biomed Mater 2017; 78:154-163. [PMID: 29156354 DOI: 10.1016/j.jmbbm.2017.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/04/2017] [Accepted: 11/09/2017] [Indexed: 11/29/2022]
Abstract
Intestinal malrotation places pediatric patients at the risk of midgut volvulus, a complication that can lead to ischemic bowel, short gut syndrome, and even death. Even though the treatments for symptomatic patients of this complication are clear, it is still a challenge to identify asymptomatic patients who are at a higher risk of midgut volvulus and decide on a suitable course of treatment. Development of an accurate computerized model of this intestinal abnormality could help in gaining a better understanding of its integral behavior. To aid in developing such a model, in the current study, we have characterized the biaxial mechanical properties of the porcine small bowel mesentery. First, the tissue stress-strain response was determined using a biaxial tensile testing equipment. The stress-strain data were then fitted into a Fung-type phenomenological constitutive model to quantify the tissue material parameters. The stress-strain responses were highly nonlinear, showing more compliance at the lower strains following by a rapid transition into a stiffer response at higher strains. The tissue was anisotropic and showed more stiffness in the radial direction. The data fitted the Fung-type constitutive model with an average R-squared value of 0.93. An averaging scheme was used to produce a set of material parameters which can represent the generic mechanical behavior of the tissue in the models.
Collapse
Affiliation(s)
- Keyvan Amini Khoiy
- Department of Biomedical Engineering, The University of Akron, Olson Research Center, 260 South Forge St., Akron, OH 44325-0302, USA
| | - Sophia Abdulhai
- Division of Pediatric Surgery, Akron Children's Hospital, Akron, OH, USA
| | - Ian C Glenn
- Division of Pediatric Surgery, Akron Children's Hospital, Akron, OH, USA
| | - Todd A Ponsky
- Division of Pediatric Surgery, Akron Children's Hospital, Akron, OH, USA
| | - Rouzbeh Amini
- Department of Biomedical Engineering, The University of Akron, Olson Research Center, 260 South Forge St., Akron, OH 44325-0302, USA.
| |
Collapse
|
30
|
Is Screening of Intestinal Foregut Anatomy in Heterotaxy Patients Really Necessary?: A Systematic Review in Search of the Evidence. Ann Surg 2017; 264:1156-1161. [PMID: 26704743 DOI: 10.1097/sla.0000000000001563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE (1) Is screening of intestinal rotational anatomy obligatory in "asymptomatic" patients with heterotaxy? (2) Does detection of an anomaly warrant surgical correction? SUMMARY OF BACKGROUND DATA Heterotaxy is an abnormal arrangement of thoraco-abdominal viscera across a left-to-right axis. Intestinal rotational anomalies are frequent among patients with heterotaxy, but debate exists as to whether they are benign in nature, requiring careful observation alone, or if surgical correction is warranted to prevent obstruction or midgut volvulus. METHODS A systematic review [according to PRISMA guidelines] was conducted using CINAHL, EMBASE, Medline, and Cochrane Databases. Article quality was assessed using MINORS criteria. Conference proceedings and unpublished data were screened additionally. RESULTS Nineteen studies met the eligibility criteria but reporting was adequate for 9. All were observational studies. These included a total of 414 patients managed expectantly, that is, "asymptomatic patients" in whom no intestinal rotation screening was undertaken (group A), 191 cases in whom screening was performed routinely (group B), and 92 patients considered "symptomatic" of potential rotational anomalies and therefore underwent imaging or laparotomy (group C). In group A, 1 patient developed symptoms attributable to malrotation in whom laparotomy confirmed the diagnosis (0.24%). Among groups B and C, 151 had Ladd's operations (53%) and 14 cases of malrotation with obstruction or volvulus were described (4.9%), of which 2 "symptomatic patients" died before laparotomy. Overall surgical complication rate was 17% with 30-day mortality rate of 2.6% to 4.6%. CONCLUSION The evidence base for screening "asymptomatic" patients is weak especially considering the life-limiting comorbidities.
Collapse
|
31
|
Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis. Pediatr Surg Int 2016; 32:1157-1164. [PMID: 27709290 DOI: 10.1007/s00383-016-3974-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Although the principles of the Ladd's procedure for intestinal malrotation in children have remained unchanged since its first description, in the era of minimally invasive surgery it is controversial whether laparoscopy is advantageous over open surgery. The aim of our study was to determine whether the surgical approach for the treatment of malrotation had an impact on patient outcome. METHODS Using a defined strategy (PubMed, Cochrane, Embase and Web of Science MeSH headings), two investigators independently searched for studies comparing open versus laparoscopic Ladd's procedure in children. Case reports and opinion articles were excluded. Outcome measures included age at operation, time to full enteral feeding, length of hospital stay, and post-operative complications. Maneuvers were compared using Fisher's exact test and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± SD. RESULTS Of 308 abstracts screened, 49 full-text articles were analyzed and nine (all retrospective) met our search criteria. Selected articles included 1003 patients, of whom 744 (74 %) underwent open surgery and 259 (26 %) laparoscopy. Patients who had open surgery were younger (0.9 ± 1.2 years) than those who underwent laparoscopy (2.6 ± 3 years; p < 0.0001). Laparoscopy was converted to open Ladd's in 25.3 % patients. Laparoscopy was associated with faster full enteral feeding (1.5 ± 0.3 days) in comparison to open surgery (4.6 ± 0.1 days, p < 0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9 ± 4.3 days) than in the open group (11.2 ± 6.7 days; p < 0.0001). Open surgery was associated with higher overall post-operative complication rate (21 %) than laparoscopy (8 %; p < 0.0001). Although there was no difference in the prevalence of post-operative bowel obstruction (open, n = 10 %; laparoscopy, n = 0 % p = 0.07), post-operative volvulus was more frequent in the laparoscopy group (3.5 %) than in the open group (1.4 %, p = 0.04). CONCLUSION Comparative but non-randomized studies indicate that laparoscopic Ladd's procedure is not commonly performed in young children. Although one third of laparoscopic procedures is converted to open surgery, laparoscopy is associated with shorter time to full enteral feeds and length of hospital stay. However, laparoscopic Ladd's procedure seems to have higher incidence of post-operative volvulus. Prospective randomized studies with long follow-up are needed to confirm present outcome data and determine the safety and effectiveness of the laparoscopic approach.
Collapse
|
32
|
Abstract
Intestinal rotation abnormality (IRA) predisposes to lethal midgut volvulus. An understanding of intestinal development illustrates the process of normal intestinal rotation and fixation. An appreciation of the clinical presentation and consequences of missed IRA will enhance clinical suspicion and timely evaluation. Selecting the appropriate imaging modality to diagnose IRA requires an understanding of the benefits and limitations of each. The Ladd's procedure continues to be the appropriate surgical treatment for IRA with or without volvulus. Laparoscopy has emerged as an option for the diagnosis and treatment of IRA. Populations in which IRA is always associated, but a Ladd's procedure rarely required, include patients with congenital diaphragmatic hernia and abdominal wall defects. Prevalence of IRA is higher in children with congenital heart disease and heterotaxy syndrome; asymptomatic patients require multidisciplinary consideration of the risks and benefits of screening for IRA, whether a Ladd's procedure is required, and the timing thereof. [Pediatr Ann. 2016;45(7):e247-e250.].
Collapse
|
33
|
Fernandez-Moure JS, Moses ML, Garcia A, Reader MM. An unusual presentation of congenital intestinal malrotation in a nonagenarian. Int J Surg Case Rep 2016; 25:229-33. [PMID: 27399168 PMCID: PMC4941200 DOI: 10.1016/j.ijscr.2016.06.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/28/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Appendicitis is a common surgical pathology with many clinical presentations. Diagnosis can be challenging if there is an alteration to the normal position of anatomical structures and their relationships. CASE PRESENTATION In this case, we report an unusual presentation of congenital intestinal malrotation in a nonagenarian presenting with generalized abdominal pain and lactic acidosis found to have perforated appendicitis. The patient was admitted to the Hospitalist service for abdominal pain and misdiagnosed with bowel obstruction secondary to previous "operation". After further review of imaging malrotation with internal hernia was suggested. The patient was taken emergently to the operating room and found to have perforated and gangrenous appendix in the midabdomen. An appendectomy was performed and patient was ultimately discharged home in good condition on postoperative day four. DISCUSSION Malrotation of the intestines is a developmental variant that occurs when normal fetal rotation of the intestines around the superior mesenteric artery and their peritoneal fixation fails to occur. Presentation typically occurs during infancy and diagnosis in an elderly patient is exceedingly rare. Operative intervention is often required as it is commonly associated with lactic acidosis or peritonitis. CONCLUSIONS Malrotation can go undiagnosed well into elderly life and can present with unusual signs and symptoms. CT is very helpful in aiding the diagnosis but itself can be misleading.
Collapse
Affiliation(s)
- Joseph S Fernandez-Moure
- Houston Methodist Hospital, Department of Surgery, 6565 Fannin St., Houston, TX 77030, United States; Houston Methodist Research Institute, Department of Regenerative and Biomimetic Medicine, Surgical Advanced Technologies Lab, 6670 Bertner Ave., Houston, TX, 77030, United States.
| | - Maya L Moses
- University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77030, United States.
| | - Andres Garcia
- University of Texas Health Science Center at Houston, 7000 Fannin St., Houston, TX, 77030, United States.
| | - Michael M Reader
- Houston Methodist Hospital, Department of Surgery, 6565 Fannin St., Houston, TX 77030, United States.
| |
Collapse
|
34
|
Cullis PS, Siminas S, Salim A, Johnson R, Losty PD. Heterotaxy and intestinal rotation anomalies: 20 years experience at a UK regional paediatric surgery centre. Pediatr Surg Int 2015; 31:1127-31. [PMID: 26243388 DOI: 10.1007/s00383-015-3755-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The association of heterotaxy with intestinal rotation anomalies is well described. However debate exists with regard optimal management notably should 'asymptomatic' bowel rotation anomalies undergo operation? The present study therefore sought to determine: (1) the risk(s) of volvulus in patients diagnosed with heterotaxy and (2) define morbidity associated with operation for 'asymptomatic' anomalies in a fragile patient cohort with co-existent congenital heart disease. METHODS Medical case record reviews of ALL heterotaxy patients born during January 1993-December 2013 and attending a UK paediatric centre were analyzed. RESULTS Of a total of 92 patients, 16 (17.4%) cases underwent foregut imaging studies. Three examinations were performed in 'symptomatic' patients. Twelve studies reported 'abnormal anatomy' with only five patients undergoing surgical correction. No complication(s) were recorded after Ladd's operation to correct defects. A single fatality occurred within 30 days postoperatively from cardiac failure. In 87 patients in whom Ladd's operation was not undertaken, no single patient developed intestinal volvulus (median length of follow-up 27.2 months, total 446.1 person years). CONCLUSION This study strongly supports a 'watchful waiting' policy for heterotaxy patients. Many children who ultimately die from heart disease may avoid unnecessary abdominal surgery.
Collapse
Affiliation(s)
- Paul S Cullis
- Department of Surgical Paediatrics, The Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
| | - Sotirios Siminas
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Adeline Salim
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Robert Johnson
- Department of Paediatric Cardiology, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK. .,Institute of Child Health, University of Liverpool, Liverpool, UK.
| |
Collapse
|
35
|
Graziano K, Islam S, Dasgupta R, Lopez ME, Austin M, Chen LE, Goldin A, Downard CD, Renaud E, Abdullah F. Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg 2015. [PMID: 26205079 DOI: 10.1016/j.jpedsurg.2015.06.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. METHODS Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. RESULTS There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. CONCLUSIONS There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
Collapse
Affiliation(s)
- Kathleen Graziano
- Division of Pediatric General Surgery, Phoenix Children's Hospital, Phoenix, AZ.
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary Austin
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center; Department of Pediatric Surgery, University of Texas Medical School, Houston, TX
| | - Li Ern Chen
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, WA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD; Department of Surgery, University of Louisville, Louisville, KY
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Department of Surgery, Albany Medical Center, Albany, NY
| | - Fizan Abdullah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
36
|
Soffers JHM, Hikspoors JPJM, Mekonen HK, Koehler SE, Lamers WH. The growth pattern of the human intestine and its mesentery. BMC DEVELOPMENTAL BIOLOGY 2015; 15:31. [PMID: 26297675 PMCID: PMC4546136 DOI: 10.1186/s12861-015-0081-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 10/30/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND It remains unclear to what extent midgut rotation determines human intestinal topography and pathology. We reinvestigated the midgut during its looping and herniation phases of development, using novel 3D visualization techniques. RESULTS We distinguished 3 generations of midgut loops. The topography of primary and secondary loops was constant, but that of tertiary loops not. The orientation of the primary loop changed from sagittal to transverse due to the descent of ventral structures in a body with a still helical body axis. The 1st secondary loop (duodenum, proximal jejunum) developed intraabdominally towards a left-sided position. The 2nd secondary loop (distal jejunum) assumed a left-sided position inside the hernia before returning, while the 3rd and 4th secondary loops retained near-midline positions. Intestinal return into the abdomen resembled a backward sliding movement. Only after return, the 4th secondary loop (distal ileum, cecum) rapidly "slid" into the right lower abdomen. The seemingly random position of the tertiary small-intestinal loops may have a biomechanical origin. CONCLUSIONS The interpretation of "intestinal rotation" as a mechanistic rather than a descriptive concept underlies much of the confusion accompanying the physiological herniation. We argue, instead, that the concept of "en-bloc rotation" of the developing midgut is a fallacy of schematic drawings. Primary, secondary and tertiary loops arise in a hierarchical fashion. The predictable position and growth of secondary loops is pre-patterned and determines adult intestinal topography. We hypothesize based on published accounts that malrotations result from stunted development of secondary loops.
Collapse
Affiliation(s)
- Jelly H M Soffers
- Department of Anatomy & Embryology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Jill P J M Hikspoors
- Department of Anatomy & Embryology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Hayelom K Mekonen
- Department of Anatomy & Embryology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - S Eleonore Koehler
- Department of Anatomy & Embryology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Wouter H Lamers
- Department of Anatomy & Embryology, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
- Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
37
|
Abstract
PURPOSE OF REVIEW At present, there is a debate as to the management of malrotation in pediatric patients. This review highlights recent literature including the role of laparoscopy, and the management of asymptomatic patients with and without congenital cardiac disease. RECENT FINDINGS Symptomatic patients are still recommended to undergo open Ladd's procedure. Laparoscopic Ladd's procedure in asymptomatic patients confers a shorter time to tolerating feeds, shorter length of stay, and a decreased rate of bowel obstruction and other complications. It may, however, carry a higher risk of postoperative volvulus. Diagnostic laparoscopy is recommended in asymptomatic patients in whom the diagnosis is uncertain on upper gastrointestinal imaging. Asymptomatic patients with congenital heart disease may be managed with initial observation or operation, based upon individualized risk benefit assessment. If an elective Ladd's procedure is performed, it should take place after palliative cardiac operations have resulted in stable cardiac function. Screening upper gastrointestinal studies in heterotaxy patients may be unnecessary as the reported rates of volvulus in recent studies are low. SUMMARY Laparoscopic Ladd's procedure may be an acceptable alternative to an open procedure for asymptomatic patients. Observation of asymptomatic patients with congenital cardiac disease is a reasonable alternative in selected patients.
Collapse
|
38
|
Chesley PM, Melzer L, Bradford MC, Avansino JR. Association of anorectal malformation and intestinal malrotation. Am J Surg 2015; 209:907-11; discussion 912. [DOI: 10.1016/j.amjsurg.2014.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/22/2014] [Accepted: 12/30/2014] [Indexed: 11/16/2022]
|
39
|
Vural V, Türkoğlu MA, Karatas G. Incidental midgut malrotation detected during second laparotomy: Case report and literature review. Int J Surg Case Rep 2014; 7C:134-6. [PMID: 25533325 PMCID: PMC4336386 DOI: 10.1016/j.ijscr.2014.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 11/14/2022] Open
Abstract
Introduction Intestinal malrotation is defined as intestinal nonrotation or incomplete rotation around superior mesenteric artery (SMA), involving anomalies of intestinal fixation as well. The patients may be recognized incidentally during other surgical procedures or at autopsy. Here in, we present a case of midgut malrotation which was diagnosed incidentally during hepaticojejunostomy procedure for benign biliary stricture. Presentation of case A 46 years old male patient was referred to our clinic with failed surgery for biliary stricture due to extensive adhesions. Prior to our surgery, intestinal malrotation was not reported and noticed by the diagnostic tools. When the patient underwent relaparotomy, midgut malrotation was observed. Discussion Distruption in the normal embryological development of bowel is the cause of intestinal malrotation. Various anatomic configurations and anomalies resulting from rotation anomalies of midgut. Adult patients are usually asymptomatic and the anomaly is discovered only at autopsy or incidentally at surgery. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated. Conclusion Performing loop hepaticojejunostomy with Braun enteroenterostomy is feasible and acceptable option rather than Roux-N-Y hepaticojejunostomy in case of intestinal malrotation.
Collapse
Affiliation(s)
- Veli Vural
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Mehmet Akif Türkoğlu
- Department of General Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | | |
Collapse
|
40
|
Robotic-assisted laparoscopic Ladd procedure for an adult with malrotation: case report and review. J Robot Surg 2014. [DOI: 10.1007/s11701-014-0467-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
41
|
Intestinal malrotation: a rare cause of small intestinal obstruction. Case Rep Surg 2014; 2014:453128. [PMID: 25371842 PMCID: PMC4209785 DOI: 10.1155/2014/453128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 09/10/2014] [Accepted: 09/15/2014] [Indexed: 11/23/2022] Open
Abstract
Background. The diagnosis of intestinal malrotation is established by the age of 1 year in most cases, and the condition is seldom seen in adults. In this paper, a patient with small intestinal malrotation-type intraperitoneal hernia who underwent surgery at an older age because of intestinal obstruction is presented. Case. A 73-year-old patient who presented with acute intestinal obstruction underwent surgery as treatment. Distended jejunum and ileum loops surrounded by a peritoneal sac and located between the stomach and transverse colon were determined. The terminal ileum had entered into the transverse mesocolon from the right lower part, resulting in kinking and subsequent segmentary obstruction. The obstruction was relieved, and the small intestines were placed into their normal position in the abdominal cavity.
Conclusion. Small intestinal malrotations are rare causes of intestinal obstructions in adults. The appropriate treatment in these patients is placement of the intestines in their normal positions.
Collapse
|
42
|
Tackett JJ, Muise ED, Cowles RA. Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency. World J Radiol 2014; 6:730-736. [PMID: 25276316 PMCID: PMC4176790 DOI: 10.4329/wjr.v6.i9.730] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 04/15/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The most accurate and practical imaging algorithm for the diagnosis of intestinal malrotation can be a complex and sometimes controversial topic. Since 1900, significant advances have been made in the radiographic assessment of infants and children suspected to have anomalies of intestinal rotation. We describe the current methods of abdominal imaging of malrotation along with their pros and cons. When associated with volvulus, malrotation is a true surgical emergency requiring rapid diagnosis and treatment. We emphasize the importance of close cooperation and communication between radiology and surgery to perform an effective and efficient diagnostic evaluation allowing prompt surgical decision making.
Collapse
|
43
|
Salústio R, Nabais C, Paredes B, Sousa FV, Porto E, Fradique C. Association of intestinal malrotation and Bochdalek hernia in an adult: a case report. BMC Res Notes 2014; 7:296. [PMID: 24886112 PMCID: PMC4030037 DOI: 10.1186/1756-0500-7-296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 05/09/2014] [Indexed: 11/26/2022] Open
Abstract
Background Late presentations of congenital diaphragmatic hernia are rare and differ from the classic neonatal presentation. The association with other congenital malformations in children, mainly intestinal malrotation, is well documented. The diagnosis of this association in adults is very rare, and depends on a high degree of suspicion. Case presentation We report a case of a 50-year-old female Caucasian patient with a previous history of intestinal malrotation diagnosed in adolescence and treated conservatively. She was referred to the hospital with signs and symptoms of intestinal obstruction. The patient undertook computed tomography that confirmed small bowel obstruction with no obvious cause, and a right subphrenic abscess with right empyema was also present. An exploratory laparotomy was performed that revealed an intestinal malrotation associated with a right gangrenous and perforated Bochdalek hernia. Resection of the affected small bowel, closure of the Bochdalek foramen and the Ladd procedure were carried out. Conclusion This case shows a rare association of two rare conditions in adults, and highlights the challenge in reaching the diagnosis and management options.
Collapse
Affiliation(s)
| | - Celso Nabais
- Department of Surgery, Hospital de São José, Centro Hospitalar de Lisboa Central, Serviço de Cirurgia 1, Rua José António Serrano, 1150-199 Lisboa, Portugal.
| | | | | | | | | |
Collapse
|
44
|
Intestinal malrotation in monozygotic twins; the asymptomatic twin should be screened: A case report and review. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
|
45
|
Carcinoma of the colon in an adult with intestinal malrotation. Case Rep Surg 2013; 2013:525081. [PMID: 23984165 PMCID: PMC3745926 DOI: 10.1155/2013/525081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 05/26/2013] [Indexed: 11/17/2022] Open
Abstract
Colon cancer is the third most common cancer in the USA. Intestinal malrotation diagnosed in adulthood was, until recently, a very rare phenomenon. While patients may present with intestinal obstruction or abdominal pain, the diagnosis is now often made as an incidental finding by computed tomography (CT). Surprisingly we found only seven case reports of carcinoma of the colon in patients with malrotation; CT failed to make the preoperative diagnosis in a majority. Laparoscopic colon surgery is rapidly becoming standard of care for colon cancer. We present a case of carcinoma of the colon in an adult that thwarted attempts at laparoscopic resection due to failure to recognize malrotation preoperatively. The literature is reviewed, and the implications of malrotation in patients with colon cancer are examined.
Collapse
|
46
|
Taslakian B, Issa G, Hourani R, Akel S. Left-sided appendicitis in children with congenital gastrointestinal malrotation: a diagnostic pitfall in the emergency department. BMJ Case Rep 2013; 2013:bcr-2013-009474. [PMID: 23761499 DOI: 10.1136/bcr-2013-009474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acute appendicitis is one of the most common conditions requiring emergency surgery. However, acute appendicitis presenting with left lower quadrant abdominal pain is extremely rare. Imaging, particularly CT , plays an important role in establishing an accurate and prompt diagnosis, as delay in diagnosis may occur due to lack of uniformity in the clinical signs and symptoms. We report a rare case of a 10-year-old boy who presented with persistent left lower quadrant pain of several days duration, in which the CT scan of the abdomen and pelvis was essential in establishing the correct diagnosis. The malpositioned inflamed appendix was clearly identified in the left side of the abdomen, with the characteristic CT findings of uncomplicated intestinal malrotation. Left-sided acute appendicitis should be considered in the differential diagnosis of young patients presenting with left lower quadrant pain, in order to avoid delay in diagnosis and guide the surgical intervention.
Collapse
Affiliation(s)
- Bedros Taslakian
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | | |
Collapse
|
47
|
Papillon S, Goodhue CJ, Zmora O, Sharma SS, Wells WJ, Ford HR, Upperman JS, Wang KS, Bushman GA, Kim R, Pierce JR. Congenital heart disease and heterotaxy: upper gastrointestinal fluoroscopy can be misleading and surgery in an asymptomatic patient is not beneficial. J Pediatr Surg 2013; 48:164-9. [PMID: 23331810 DOI: 10.1016/j.jpedsurg.2012.10.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/13/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Heterotaxy syndrome is associated with intestinal abnormalities. We sought to define the gastrointestinal anatomy and determine both the risk of volvulus and benefit of screening upper gastrointestinal fluoroscopy (UGI) in these patients. METHODS Medical records from 2003 until 2011 at Children's Hospital Los Angeles were reviewed in patients with heterotaxy for cardiovascular diagnosis, gastrointestinal symptoms, imaging and surgical arrangement of viscera, perioperative morbidities, and overall mortality. RESULTS 224 patients were identified. Fifteen had polysplenia, 41 had asplenia, 50 had normal splenic morphology, 13 had inversus, and 104 were uncharacterized. UGI was performed in 4 patients for suspected volvulus and 20 for obstructive symptoms. Sixty-two had "screening" UGIs. Of 138 asymptomatic patients without imaging, none developed volvulus during the study period. In 30 patients with duodenojejunal malposition (DJM) who underwent surgery, none had malrotation or narrow mesentery. Eleven developed complications, with 8 requiring reoperation for obstruction. Of 8 patients with malrotation, 7 received a Ladd's procedure, and 2 had volvulus with viable bowel. One patient required reoperation and resection for obstruction. CONCLUSION While rotational abnormalities are common in heterotaxy, risk of volvulus is low. Following operation, the risk of bowel obstruction and of need for reoperation is higher. We advocate avoiding operation in the asymptomatic patient.
Collapse
Affiliation(s)
- Stephanie Papillon
- Department of Pediatric Surgery, Children's Hospital Los Angeles, CA 90027, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Nath J, Corder AP. Delayed presentation of familial intestinal malrotation with volvulus in two adult siblings. Ann R Coll Surg Engl 2012; 94:e191-2. [PMID: 22943318 PMCID: PMC3954358 DOI: 10.1308/003588412x13373405384819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Familial cases of malrotation are extremely rare in the absence of other congenital malformations. We present the case of a 22-year-old woman with undiagnosed chronic abdominal pain and her previously well 16-year-old brother who presented within 18 months of each other with acute midgut volvulus secondary to intestinal malrotation. Clinicians should be aware of this rare but serious cause of abdominal pain.
Collapse
Affiliation(s)
- J Nath
- Wye Valley NHS Trust, UK.
| | | |
Collapse
|
49
|
Nagdeve NG, Qureshi AM, Bhingare PD, Shinde SK. Malrotation beyond infancy. J Pediatr Surg 2012; 47:2026-32. [PMID: 23163993 DOI: 10.1016/j.jpedsurg.2012.06.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 05/25/2012] [Accepted: 06/19/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of this work was to study the various presentations of malrotation and management in patients older than 1 year. MATERIALS AND METHODS Medical records of patients operated on over the last 6 years who were older than 1 year with a diagnosis of intestinal malrotation were evaluated retrospectively. Data about age at presentation, sex, presenting symptoms, time to diagnosis, radiographic imaging performed, surgical intervention, complications, and postoperative follow-up were collected and evaluated. RESULTS The study population included 35 children and 3 adults. About three-fourths of pediatric patients were younger than 5 years, and about half of these presented in the second year of life. All patients who presented in the second year of life had a classical presentation of malrotation. Older patients presented more commonly with atypical symptoms. Of these, 5 older children were previously treated for suspected diagnosis of abdominal tuberculosis. Two patients were referred for acute pancreatitis and 1 for severe gastroesophageal reflux disease. Three adults presented with acute small intestinal obstruction and were diagnosed to have malrotation intraoperatively. Upper gastrointestinal contrast study was diagnostic of malrotation in all pediatric patients. Ultrasound and color Doppler study of the abdomen revealed abnormal relationship of the superior mesenteric artery and vein in about one-third of the patients. All patients underwent a standard Ladd procedure. Midgut volvulus was present in about one-fourth of patients. Forty percent of patients with atypical presentation had persistence of preoperative symptoms postoperatively. Two adults developed complications postoperatively. There was no mortality in the present study. CONCLUSION Malrotation should be suspected in all patients with varied acute or chronic abdominal symptoms, and the upper gastrointestinal contrast study should be conducted. If the existence of typical malrotation is confirmed, surgical correction is mandatory to avoid volvulus and intestinal obstruction independently of the patient's age.
Collapse
Affiliation(s)
- Nilesh G Nagdeve
- Department of Surgery, Pediatric Surgery Unit, Government Medical College, Nagpur 44003, India.
| | | | | | | |
Collapse
|
50
|
Abstract
Intestinal malrotation is well covered in the surgical literature from the point of view of operative management, but few reviews to date have attempted to provide a comprehensive examination of the topic from the point of view of aetiology, in particular genetic aetiology. Following a brief overview of molecular embryology of midgut rotation, we present in this article instances of and case reports and case series of intestinal malrotation in which a genetic aetiology is likely. Autosomal dominant, autosomal recessive, X-linked and chromosomal forms of the disorder are represented. Most occur in syndromic form, that is to say, in association with other malformations. In many instances, recognition of a specific syndrome is possible, one of several examples discussed being the recently described association of intestinal malrotation with alveolar capillary dysplasia, due to mutations in the forkhead box transcription factor FOXF1. New advances in sequencing technology mean that the identification of the genes mutated in these disorders is more accessible than ever, and paediatric surgeons are encouraged to refer to their colleagues in clinical genetics where a genetic aetiology seems likely.
Collapse
|