Should malrotation in children be treated differently according to age?

High risk and low incidence diseases: Pediatric digestive volvulus

INTRODUCTION

Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments.

CONCLUSION

An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Impact of Focused Abdominal Ultrasound Utilization on Outcomes for Children With Midgut Volvulus

BACKGROUND

Ultrasound (US) is gaining acceptance for the evaluation of midgut volvulus in children. However, its impact on clinical outcomes is unknown. We aim to determine whether using US as a first-line modality changes imaging mobilization, time to surgery and re-feeding, length of stay, and frequency of bowel necrosis, short bowel syndrome, and death.

METHODS

An IRB-approved retrospective cohort study was performed at a tertiary pediatric institution. Eighty children with surgically confirmed midgut volvulus from 2014 to 2021 were compared before and after implementation of US as first-line imaging and based on the modality used to diagnose midgut volvulus.

RESULTS

Outcomes were not statistically different pre- versus post-implementation. Compared with patients who had UGI only, those who had US only or both had significantly quicker imaging mobilization (median: -33 min; 95% CI: -61.2, -4.8; p = 0.023 and median: -31 min; 95% CI: -58.5, -3.6; p = 0.028 respectively). Patients with US only were less likely to have bowel necrosis compared with those who had UGI only (9.1% versus 43.8%, p = 0.042). Patients who had US only or both were less likely to develop short bowel syndrome compared to UGI only (4.8% US only, 0% both, 40% UGI only; p = 0.027 for US only, p = 0.005 for both).

CONCLUSIONS

No statistically significant change in outcomes was found after implementation of US as first-line imaging for midgut volvulus. However, patients diagnosed with US only or US in combination with UGI had quicker imaging mobilization and decreased frequency of bowel necrosis and short bowel syndrome. Findings suggest that US has potential to improve patient outcomes.

LEVEL OF EVIDENCE

III.

Persistent and newly developed gastrointestinal symptoms after surgery for intestinal malrotation in children: Dysmotility or disorders of gut and brain interaction?

OBJECTIVES

Surgery for intestinal malrotation (IM) aims to correct the defect and improve symptoms; however, many have persistent gastrointestinal (GI) symptoms postoperatively. We evaluated the incidence, clinical presentation, and long-term outcomes of children with surgically repaired IM and its possible association with disorders of gut and brain interaction (DGBI).

METHODS

Multicenter retrospective study was conducted in patients from 0 to 21 years old, who had surgery for IM from 2000 to 2021 across three pediatric tertiary care centers. Data analyzed included demographics, time to diagnosis, idiopathic diagnosis, incidental diagnosis, postoperative follow-up, surgical time, and the need for surgery including bowel detorsion. Outcome variables were the presence of postoperative GI symptoms and DGBIs, and overall resolution of symptoms. We also evaluated the potential association of demographics and other included variables with our outcome variables.

RESULTS

Ninety-two patients with surgically corrected IM were included, 54% were male, and median age of diagnosis and surgical correction was 4.9 and 7.8 months, respectively. Median follow-up after surgery was 64 months. A total of 77% had postoperative GI symptoms, and notably, 78% of patients without symptoms before surgery (incidental diagnosis) developed GI symptoms postoperatively and 27% of patients met Rome IV criteria for a one or more DGBI. No factors were associated to the presence of postoperative symptoms or DGBIs in multivariate analysis. Female gender was the only factor associated with lack of resolution of symptoms at follow-up.

CONCLUSION

Pediatric IM is commonly associated with postoperative GI symptoms and DGBI well beyond surgery. An increased awareness about the prevalence of DGBI in these patients may help reach a prompt and accurate diagnosis, and improve their quality of life.

Outcomes after Ladd Procedures for Intestinal Malrotation in Newborns with Heterotaxy Syndrome

PURPOSE

Intestinal malrotation may be asymptomatic in patients with heterotaxy syndrome (HS), and whether these newborns benefit from prophylactic Ladd procedures is unknown. This study sought to uncover nationwide outcomes of newborns with HS receiving Ladd procedures.

METHODS

Newborns with malrotation were identified from the Nationwide Readmission Database (2010-2014) and stratified into those with and without HS utilizing ICD-9CM codes for situs inversus (759.3), asplenia or polysplenia (759.0), and/or dextrocardia (746.87). Outcomes were analyzed using standard statistical tests.

RESULTS

4797 newborns with malrotation were identified, of which 16% had HS. Ladd procedures were performed in 70% overall and more common in those without heterotaxy (73% vs. 56% HS). Ladd procedures in newborns with heterotaxy were associated with higher complications compared to those without HS including surgical site reopening (8% vs. 1%), sepsis (9% vs. 2%), infections (19% vs. 11%), venous thrombosis (9% vs. 1%), and prolonged mechanical ventilation (39% vs. 22%), all p < 0.001. HS newborns were less frequently readmitted with bowel obstructions (0% vs. 4% without HS, p < 0.001) with no readmissions for volvulus in either group.

CONCLUSION

Ladd procedures in newborns with heterotaxy were associated with increased complications and cost without differences in rates of volvulus and bowel obstruction on readmission.

TYPE OF STUDY

Retrospective Comparative.

LEVEL OF EVIDENCE

III.

Predictive factors of bowel resection for midgut volvulus based on an analysis of bi-center experiences in southern Japan

PURPOSE

Midgut volvulus is an urgent disease often occurring in neonates. This study clarified the clinical features of midgut volvulus and evaluated predictors to avoid bowel resection.

METHODS

This bi-center retrospective study enrolled 48 patients who underwent surgery for intestinal malrotation between 2010 and 2022. Patients' background characteristics and preoperative imaging findings were reviewed.

RESULTS

Midgut volvulus was recognized in 32 patients (66.7%), and 6 (12.5%) underwent bowel resection. Based on a receiver operating curve analysis of bowel resection, the cut-off value of the body weight at birth and at operation were 1984 g [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.52-0.99] and 2418 g (AUC 0.70, 95% CI 0.46-0.94), respectively. The cut-off value of intestinal torsion was 540° (AUC 0.76, 95% CI 0.57-0.95), and that of the time from the onset to the diagnosis was 12 h (AUC 0.85, 95% CI 0.72-0.98). For midgut volvulus with an intestinal torsion > 540°, the most sensitive preoperative imaging test was ultrasonography (75%) Patients with bloody stool tended to undergo bowel resection.

CONCLUSIONS

Patients with a low body weight and bloody stool should be confirmed to have whirlpool sign by ultrasonography and scheduled for surgery as soon as possible.

Therapeutic actions in a 2-month-old child with teratoma and duodenal malrotation accompaniment

Introduction

and importance: A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues and it is usually considered benign, more common in female and may require surgical removal. The most common locations for teratomas are the tailbone (coccyx), ovaries, and testicles, but in this case, the teratoma was located in the mediastinum.

Case presentation

Furthermore, intestinal malrotation could potentially lead the patient to gastrointestinal (GI) obstruction and PO intolerance. Here, we present a 2-month-old patient with considerable manifestation of GI intolerance due to intestinal malrotaion accompanied by mature mediastinal teratoma.

Clinical discussion

An evaluation of malrotation should be part of every upper GI tract examination in pediatric patients, particularly newborns and infants.

Conclusion

Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

•

A mature mediastinal teratoma is a rare type of tumor that can contain fully developed tissues.

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Benign, more common in female and may require surgical removal.

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Evaluation for malrotation should be part of every upper GI tract examination in pediatric patients.

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In this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

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Finally, in this case, surgical intervention could enhance both malrotation and mediastinal teratoma.

Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review

Midgut volvulus in association with malrotation is a pediatric surgical emergency. Prompt and accurate diagnosis is necessary to avoid bowel ischemia and necrosis, thereby reducing morbidity and mortality. Historically, the upper gastrointestinal (UGI) series has been the preferred imaging modality for the evaluation of both midgut malrotation and volvulus, although use of ultrasound (US) is increasing. In this narrative review, we describe the findings of midgut malrotation and volvulus on US, including practical tips for acquisition and interpretation; discuss the advantages and challenges of both imaging modalities; and propose a path and safeguards for possible transition to the use of US as the first-line modality for diagnosis, based on our experience in imaging children with midgut malrotation and volvulus.

A problem at any age: a case report of congenital malrotation with bowel ischemia in an 84-year-old

Background

Malrotation with bowel ischemia is classically thought of as a disease of infants. However, the true prevalence of malrotation in both the pediatric and adult population is unknown due to the unclear number of asymptomatic patients.

Case presentation

A previously healthy 84-year-old man with no prior abdominal surgeries presented with an acute abdomen and was found on CT to have small bowel located in the right hemiabdomen and an abnormal SMA-SMV relationship suggestive of intestinal malrotation, as well as pneumatosis intestinalis. He underwent an exploratory laparotomy, where he was found to have a paraduodenal space which did not contain any bowel but was the likely source of an internal hernia. His duodenojejunal flexure was located to the right of the spinal column, the cecum in the left lower quadrant, a thick congenital band at the proximal jejunum, and multiple Ladd’s bands at the level of the duodenum. The bowel appeared viable and a Ladd’s procedure was performed. The patient had an uneventful post-operative course.

Conclusions

There is a lack of guidelines regarding screening for and management of asymptomatic malrotation in older children and adults. However, the traditional thinking is that asymptomatic malrotation diagnosed after two years of age poses minimal risk. This case illustrates the potential risk of an internal hernia in the setting of malrotation at any time during one’s lifetime.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01482-6.

Laparoscopic Versus Open Ladd's Procedure for Intestinal Malrotation in Infants and Children: A Systematic Review and Meta-Analysis

Aim: To compare clinical outcomes in infants and children with intestinal malrotation who were treated by laparoscopic or open Ladd's. Methods: PubMed, EMBASE, and Cochrane library were searched for studies comparing laparoscopy with open Ladd's for intestinal volvulus through January 5, 2021. Search terms were confined to Title/Abstract: "Intestinal Volvulus" OR "Intestinal malrotation" AND "Laparoscopy" AND "Laparotomy." Randomized controlled trials (RCTs) and retrospective studies comparing laparoscopy with open Ladd's in neonates, infants, or children were included. Outcomes evaluated included operative time, time to full feeds, length of hospital stay, rate of conversion, reoperation, overall postoperative complications, postoperative adhesive small bowel obstruction, and postoperative volvulus. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MDs) were measured for continuous variables. Results: Fourteen studies were included, comprising 444 patients who underwent laparoscopic approach and 1422 patients who underwent open procedure. Laparoscopy group had shorter operative time (MD = -14.44 minutes, 95% confidence interval [CI] = -20.79 to -8.09, P < .00001), hospital stay (MD = -4.57 days, 95% CI = -7.58 to -1.56, P = .003), and time to full feeds (MD = -3.00 days, 95% CI = -3.80 to -2.19, P < .00001). Laparoscopic Ladd's procedure had less overall postoperative complications (OR = 0.35, 95% CI = 0.19-0.65, P = .0009), less postoperative adhesive small bowl obstruction (OR = 0.37, 95% CI = 0.19-0.74, P = .005), and more postoperative volvulus (OR = 2.97, 95% CI = 1.23-7.13, P = .02). There was no difference in incidence of reoperation rate (OR = 2.04, 95% CI = 0.96-4.33, P = .06). Conclusion: Laparoscopic procedure is superior to open Ladd's in operative time, hospital stay, time to full feeds, overall postoperative complication, and postoperative adhesive small bowel obstruction. However, more RCTs with adequate follow-up are needed to overcome the limitations of our study.

Sonographic Detection of Congenital Intestinal Malrotation: A Case Report

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.

Untwisting the complexity of midgut malrotation and volvulus ultrasound

Abdominal US is emerging as an alternative to the upper gastrointestinal (GI) series as the preferred diagnostic imaging test for midgut malrotation complicated by volvulus. Unlike the upper GI series, US is free from ionizing radiation, does not require oral contrast agent, and can be performed portably and at times remotely from the interpreting radiologist, expediting diagnosis. Although some institutions do not have a standardized US protocol for midgut volvulus, many routinely use US in the setting of an infant or child with acute abdominal signs or symptoms to evaluate for common conditions such as hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis and appendicitis. Because these common conditions can overlap in age and clinical presentation with midgut volvulus, the aim of this pictorial essay is to provide instruction on the technique and diagnostic findings of midgut volvulus on US to ensure confident, accurate interpretation, and prompt treatment.

Assessment of plasma microRNAs in congenital intestinal malrotation

Intestinal malrotation in newborns often requires urgent surgical treatment, especially in the presence of volvulus. Therefore, early-stage diagnosis is critical. In the present study, differentially expressed plasma microRNAs (miRNAs) were screened for in patients with intestinal malrotation using high-throughput Illumina sequencing, and validated using reverse transcription-quantitative PCR. Receiver operating characteristic curve (ROC) analysis was conducted to evaluate their specificity, sensitivity and assess their diagnostic value for intestinal malrotation. Bioinformatics analysis was performed to investigate the functions associated with the dysregulated miRNAs. A profile consisting of 28 differentially expressed plasma miRNAs was obtained, of which nine were verified to exhibit significantly altered expression. According to a ROC analysis, four of these could represent novel early-stage, non-invasive biomarkers for intestinal malrotation. Bioinformatics analysis demonstrated that the differentially expressed miRNAs were predominantly involved in ‘metal ion transmembrane transporter activity’ and ‘calcium-dependent protein binding’, which may be related to the ‘endocytosis’ pathway. In conclusion, significantly differentially expressed plasma miRNAs were identified in congenital intestinal malrotation and their potential roles were described. These differentially expressed miRNAs may serve as biomarkers of intestinal malrotation and improve early diagnosis for this condition.

Fluoroscopic Diagnosis of Malrotation: Technique, Challenges, and Trouble Shooting

A fluoroscopic upper gastrointestinal series is the most commonly used investigation for the diagnosis of malrotation and midgut volvulus. However, both false positive and false negative results can occur causing diagnostic confusion. Several physiologic states and pathologic conditions can mimic fluoroscopic appearance of malrotation. Proper fluoroscopic technique is essential to maximize diagnostic accuracy. In this pictorial essay, we discuss common diagnostic challenges in the diagnosis of malrotation and strategies radiologists can use to clarify the diagnosis in equivocal cases.

Laparoscopic Ladd's procedure for malrotation in infants and children is still a controversial approach

BACKGROUND

Open Ladd's procedure is the gold standard for the correction of intestinal malrotation and laparoscopic approach remains controversial. This study aimed to evaluate our experience in laparoscopic management of malrotation.

METHODS

Single center retrospective study including patients who underwent a laparoscopic assessment of intestinal malrotation with correction if appropriate between 2007 and 2017.

RESULTS

Sixty-five patients (median age 7 months) had a laparoscopic assessment with and without correction of malrotation. Forty-five (69%) were symptomatic, including 16 (25%) with a midgut volvulus. The procedure was completed laparoscopically in 55 (86%) patients in 110 min (30-190). Conversions happened more frequently at the beginning of the experience. With a follow-up of 12.5 months (8 days-5.3 years), morbidity rate was 15% and 4 (6%) patients underwent a redo surgery, all in the first 5 months after surgery, compared with 3/53 (6%) in a contemporaneous group undergoing open Ladd's.

CONCLUSION

This is the largest series reported so far of the laparoscopic management of malrotation. Laparoscopic Ladd's procedure is reliable but still exposes to open conversion which may be in part owing to a learning curve. A low conversion threshold is important in cases with volvulus. The redo rate is similar to that of the open procedure.

LEVEL OF EVIDENCE

Level III retrospective comparative treatment study.

Heterotopy ("Error loci") of the spiral loop of the ascending colon in cattle

The term heterotopy of the spiral colon encompasses a dysmorphological condition in which the spiral loops of the ascending colon (SLACs) do not form an orderly spiraling mass adjacent to the left side of the mesojejunum. As a consequence, the spiral loops are spread over a larger surface, making them more or less movable. It has been hypothesized that the abnormal position of the spiral loops of the ascending colon might constitute a predisposing factor for an intestinal obstruction or an ileus condition. The objective of the present study was to evaluate the anatomy of the spiral loops of the ascending colon in a population of healthy calves and to determine the prevalence of dysmorphism. The investigation was carried out on 1113 slaughtered veal calves. In 472 out of the 1113 calves, the spiral loops showed conformational aspects different from what has so far been described as normal in reference textbooks. In 91 calves the condition was definitely considered a pathological deviation from normality: in fact, the spiral colon had lost its typical spiral shape with random spacing between the loops, and it was nearly or completely detached from the mesojejunum. The lack of a broad attachment of the spiral loops of the ascending colon to the mesentery could provoke an alteration of the intestinal centre of gravity, enhancing the already asymmetrical distribution of weight between the jejunum and the descending colon.

An Unusual Case of Intestinal Malrotation Causing Duodenal Obstruction by a Looped Appendix

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

Novel variant of reversed midgut rotation - retro-arterial proximal jejunum and transverse colon: a case report and review of the literature

BACKGROUND

Reversed rotation of the midgut is the rarest variation of midgut malrotations, which are congenital disorders that result from aberrant rotation and fixation of the midgut during embryological development. Common complications of these disorders are small bowel obstruction by volvulus or peritoneal bands, usually occurring in early infancy.

CASE PRESENTATION

A 23-year-old Caucasian woman presented with recurrent abdominal pain. A contrast-enhanced multidetector computed tomography study revealed a novel variant of reversed rotation of the midgut. Besides the specific finding of a retro-arterial transverse colon, we also found the proximal jejunum to cross posterior to the mesenteric root, a variation that has not been reported in the literature so far. In this case, substantial symptomatic relief was achieved with conservative management.

CONCLUSIONS

The hypothesis of a double reversed rotation of the pre-arterial segment of the umbilical loop around the superior mesenteric artery axis provides a possible explanation for this anomaly. There is no evidence-based consensus on the management of patients presenting with non-symptomatic or mildly symptomatic intestinal malrotations. In this case, radiologic and clinical presentations excluded acute small bowel obstruction, and surgical intervention was avoided.

Laparoscopic diagnostic finding in atypical intestinal malrotation in children with equivocal imaging studies

BACKGROUND

Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper gastrointestinal (UGI) contrast study is essential for diagnosis; however, 'soft' radiologic findings place the responsibility of excluding malrotation directly on the surgeon. Recently, minimally invasive surgical techniques would be able to accomplish the identical evaluation and treatment of this group of patients.

PATIENTS AND METHODS

A total of 40 patients (25 male, 15 female), age of 2-14 years, presented with symptoms of chronic abdominal pain, intermittent upper intestinal obstruction, recurrent bilious vomiting and failure to thrive. On clinical examination, none of the patients had signs of acute abdominal emergency. UGI contrast study was done and it was equivocal. All patients underwent laparoscopic evaluation.

RESULTS

A total of 36 patients (90%) were found on laparoscopy to have a discrepant finding of chronic intestinal malrotation. With narrow mesenteric base which put them at significant risk of midgut volvulus. Two patients (5%) were found to have chronic appendicitis with extensive adhesion at the right iliac fossa, one patient (2.5%) has annular pancreas and one patient has negative laparoscopic exploration. Laparoscopic findings of chronic intestinal malrotation includes, huge dilated stomach and the first part of duodenum, ectopic site of caecum central in the abdomen or under the liver, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic oedema, generalised mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, right-sided small bowel.

CONCLUSION

Laparoscopic diagnostic finding permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. Furthermore, laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children with a narrow base should undergo laparoscopic Ladd procedure to avoid catastrophic midgut volvulus.

The surgical management of malrotation: A Canadian Association of Pediatric Surgeons survey

PURPOSE

Some surgeries are now performed almost exclusively via a laparoscopic approach to enhance recovery and reduce postoperative complications. This survey explored institutional and individual physician practice patterns of the surgical management of malrotation.

METHODS

All 2015 Canadian Association of Pediatric Surgeons annual meeting attendees were invited to complete an anonymous prepiloted survey. Descriptive statistics were calculated.

RESULTS

The response rate was 35% (150 distributed, 52 returned). Most institutions (39.5%) saw on average 5-10 cases of malrotation per year. Most respondents (54.2%) indicated that the laparoscopic (LL) and open Ladd's (OL) procedures were equal surgical approaches for stable patients. Respondents were nearly equally divided (47.9% yes; 44.7% no) with respect to whether an LL procedure led to a higher risk of postoperative volvulus. Of those who answered yes, most indicated that an increased risk of postoperative volvulus was because of an inadequate widening of mesentery (45.8%), reduced "beneficial" postoperative adhesions (29.2%), or both (16.7%). 100% of respondents who perform an OL as their standard procedure indicated that there was a higher risk of postoperative volvulus with LL procedure. Only 1/8 who performed a LL as a standard approach routinely performed an appendectomy.

CONCLUSION

There remain polarized views on the best surgical approach to malrotation yet a persistent belief in the reduction in postoperative adhesions in leading to a postoperative volvulus with LL procedures. Collaboration to permit long-term follow-up of a large cohort may help develop guidelines for the operative management of malrotation.

LEVEL OF EVIDENCE

Level V.

Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis

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.

Intestinal malrotation needs immediate consideration and investigation

BACKGROUND

The aim of this study was to evaluate clinical presentation, diagnostic studies, and volvulus rate and to describe the unusual clinical clues of intestinal malrotation.

METHODS

A retrospective descriptive review was carried out of all patients diagnosed with intestinal malrotation between 2002 and 2014. Patients were divided into two groups: infants (≤1 year, n = 16; group 1); and children (>1 year, n = 12; group 2). Patient demographics, clinical history, symptoms, physical examination, diagnostic work-up, operative findings and early outcome were evaluated.

RESULTS

Bilious vomiting was the cardinal complaint in both groups. Unusual symptoms such as respiratory insufficiency, dehydration, afebrile convulsion, and lethargy were prominent symptoms in six patients in group 1, whereas history of frequent hospitalization due to recurrent abdominal pain and feeding intolerance were prominent in six patients in group 2. Midgut volvulus was identified in 15 patients, four of whom were in group 2. Standard Ladd's procedure was done in addition to correction of volvulus.

CONCLUSION

Malrotation with or without midgut volvulus is not a rare condition and should be kept in mind for any age group. Specific signs of diagnosis are not easily identified. In the case of unusual clinical presentation, diagnosis may be delayed and can result in catastrophic consequences if intestinal perfusion occurs. Although midgut volvulus is seen most frequently in infants, risk and complication rate are high beyond 1 year of age as well, and can manifest as failure to thrive, food intolerance, and abdominal pain needing recurrent hospitalization. Diagnostic suspicion and interdisciplinary coordination are essential for timely diagnosis and surgical treatment.

Malrotation in infancy and childhood

BACKGROUND AND AIMS

The cardinal features of bilious vomiting and abdominal distension assist in the diagnosis of malrotation and volvulus, an often fatal condition in the neonate. When these symptoms are absent, however, diagnosis becomes trickier. In the older child, these classic symptoms are less likely to occur, or occur at a later stage, meaning these children suffer from a delay in diagnosis and consequently do poorer. There is a need, therefore, to identify the common presenting features in these older children in order to facilitate earlier diagnosis and improve outcomes.

METHODS

We reviewed the current literature (Appendix 1) and then undertook a retrospective study in our own department to explore the presenting complaint, time to diagnosis, intraoperative findings and outcome of all children over the age of 28 days who underwent a Ladd's procedure for malrotation at Royal Hospital for Sick Children, Glasgow (RHSC) between 1998 and 2014.

RESULTS

It was found that children between the ages of 28 days and 15 years are more likely to display signs and symptoms such as chronic abdominal pain and non-bilious vomiting. Their complication rate was found to be significant.

CONCLUSION

Education surrounding the timely diagnosis of malrotation in the post-neonatal child is crucial.

[Endoscopic treatment of intestinal malrotation in newborns and infants]

AIM

To compare treatment of intestinal malrotation in newborns and infants using laparoscopy and laparotomy.

MATERIAL AND METHODS

For the period from January 2004 to December 2013 34 Ladd's procedures were performed. Children were divided into 2 groups by 17 patients: laparoscopic (group I) and open treatment (group II).

RESULTS

Both groups had similar demographic and other preoperative parameters. There were significant differences in duration of operation between both groups (61 vs. 70 minutes). Nutrition was initiated earlier after mini-invasive treatment (1.5 days vs. 3 days) and the time need for full enteral nutrition was also less (4.2 days vs. 6.9 days). Hospital-stay was shorter in group I (7.7 vs. 10.2 days). Number of early postoperative complications was similar in groups. Incidence of remote complications was higher in laparotomy group but the differences were not significant.

CONCLUSION

Our results showed that endoscopic correction of congenital anomalies of intestinal rotation provides better postoperative results than open surgery and can be widely used in young children.

Concurrent perforated Meckel's diverticulum and intestinal malrotation in an 8-year-old boy

An 8-year-old boy with a history of recurrent abdominal pain presented with a 12 h history of severe periumbilical pain, nausea and vomiting. On examination, he was found to have a tender, erythematous, paraumbilical mass. At operative exploration, an abscess cavity was identified and followed to reveal a gangrenous Meckel's diverticulum, perforated at its tip to create the abscess. Around this Meckel's diverticulum, the small bowel had torted to produce a significant small bowel volvulus on a shortened mesentery. The caecum and ascending colon were found to be in the left upper quadrant and an intraoperative diagnosis of malrotation was made. Following resection of the Meckel's diverticulum and surgical correction of the malrotation, the child made an excellent recovery. His abdominal pain has not recurred in 6 months of follow-up since the operation.

Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review

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.

Early versus delayed surgical correction of malrotation in children with critical congenital heart disease

PURPOSE

The purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD).

METHODS

Patients with CHD who underwent cardiac surgery by 1 year of age and had malrotation diagnosed during their initial admission at 34 hospitals contributing to the Pediatric Health Information System in 2004-2009 were included. Ladd's procedures performed during the first admission were considered early correction, and those at a subsequent admission were considered delayed. Interhospital variability in the proportion of patients undergoing delayed correction was assessed, and outcomes were compared between the groups.

RESULTS

Of the 324 patients identified, 85.2% underwent early correction. Significant variability existed in the proportion of patients undergoing delayed correction across hospitals (p<0.0001). Baseline characteristics, including severity of CHD, were similar between the groups. In the delayed group, 27% of patients underwent a Ladd's procedure during an urgent or emergent admission, but none had volvulus or underwent intestinal resection. Rates of mortality and readmission within 1 year of malrotation diagnosis were similar in both groups. Chart validation confirmed 100% accuracy of diagnosis and treatment group assignment.

CONCLUSIONS

In patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.

Malrotation beyond infancy

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.

Midgut malrotation with chronic abdominal pain

Abnormalities in midgut rotation occur during the physiological herniation of midgut between the 5^th and 10^th week of gestation. The most significant abnormality is narrow small bowel mesentery which is prone to volvulus. This occurs most frequently in the neonatal period, less commonly midgut malrotation presents in adulthood with either acute volvulus or chronic abdominal symptoms. It is the latter group that represents a diagnostic challenge. We report a case of a 17-year-old male patient who presented with 10-year history of nonspecific gastro-intestinal symptoms. After extensive investigation the patient was diagnosed with midgut malrotation following computed tomography of abdomen. The patient was treated with a laparoscopic Ladd's procedure and at 3 months he was gaining weight and had stopped vomiting. A laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating symptomatic malrotation in adults. Midgut malrotation is a rare congenital anomaly which may present as chronic abdominal pain. Abdominal CT is helpful for diagnosis.

Surgery for suspected rotation abnormality: selection of open vs laparoscopic surgery using a rational approach

BACKGROUND

Laparoscopy is increasingly used for children with suspected rotation abnormalities. However, indications for open and laparoscopic approaches are not well defined. We reviewed our experience with both open and laparoscopic approaches to develop a rational approach to these patients.

METHODS

Charts of all children undergoing surgery for a suspected rotation abnormality for 10 years were retrospectively reviewed.

RESULTS

There were 173 patients. Of 73 neonates presenting with suspected volvulus, 71 underwent initial laparotomy and 2 were converted from initial laparoscopy. Eighty percent underwent Ladd procedure, 64% had volvulus, and 2 died of midgut volvulus. Of 18 neonates presenting without suspected volvulus, 14 underwent initial laparotomy and 4 had a laparoscopic approach with 1 conversion to laparotomy. Seventy-eight percent underwent Ladd procedure, and 22% had volvulus. Of the 82 older patients, 37 underwent laparotomy and 45 had initial laparoscopy, 8 of which were converted. Sixty-seven percent underwent Ladd procedure, and 28% had volvulus. Postoperative complication rate, median time to full diet, and median hospital stay were comparable with those previously reported in the literature.

CONCLUSION

Based on our results, we advocate open surgery for neonates with suspected volvulus. Laparoscopy represents an excellent alternative for older children and for neonates presenting without suspected volvulus.

Value of laparoscopy in children with a suspected rotation abnormality on imaging

BACKGROUND

Although imaging is usually used for the diagnosis of rotation abnormalities, significant false-positive and false-negative rates have been reported. We studied the utility of laparoscopy in the management of children with a suspected rotation abnormality on imaging.

METHODS

The charts of all children undergoing laparoscopy for a suspected intestinal rotation abnormality from January 2000 to August 2009 were retrospectively reviewed.

RESULTS

There were 51 patients. Preoperative diagnosis based on upper gastrointestinal contrast study with or without contrast enema or ultrasound was malrotation without volvulus in 47%, malrotation with volvulus in 10%, and nonrotation in 6%; the other 37% had equivocal or inconclusive imaging studies. Of the patients who had a "definitive" preoperative diagnosis, 41% had a discrepant finding at laparoscopy. For those with inconclusive imaging studies, 32% were found on laparoscopy to have a narrow mesenteric base, which put them at significant risk of midgut volvulus.

CONCLUSION

Imaging studies may be inaccurate in differentiating malrotation from nonrotation or normal rotation. Laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children without a narrow-based mesentery can undergo laparoscopy alone, and those with malrotation should undergo either laparoscopic or open Ladd procedure.

Laparoscopic treatment of intestinal malrotation in neonates and infants: retrospective study

Background

Intestinal malrotation in neonates or infants may require urgent surgical treatment, especially when volvulus and vascular compromise of the midgut are suspected. Successful laparoscopic management of malrotation has been described in a number of case reports. It remains unclear, however, whether laparoscopy for the treatment of malrotation has a success rate equal to that of open surgery and what relative risks exist in terms of conversion and redo surgery in larger numbers of patients. This report describes a retrospective analysis of the clinical outcome for 45 children who underwent laparoscopic treatment of intestinal malrotation at the authors’ institution.

Methods

The 45 patients in this series, ages several days to 13 years, underwent a diagnostic laparoscopy for suspected intestinal malrotation. For 37 patients, malrotation with or without volvulus was diagnosed. All these patients underwent laparoscopic derotation and Ladd’s procedure.

Results

Successful laparoscopic treatment of intestinal malrotation could be performed in 75% of the cases (n = 28), and conversion to an open procedure was necessary in 25% of the cases (n = 9). The median hospital stay was 11 days (range, 2–60 days). Postoperative clinical relapse due to recurrence of malrotation, volvulus, or both occurred for 19% of the laparoscopically treated patients (n = 7). These patients underwent laparoscopic (n = 1) or open (n = 6) redo surgery.

Conclusion

Diagnostic laparoscopy is the procedure of choice when intestinal malrotation is suspected. If present, malrotation can be treated adequately with laparoscopic surgery in the majority of cases. Nevertheless, to prevent recurrence of malrotation or volvulus, a low threshold for conversion to an open procedure is mandated.

Congenital anomalies of the gastrointestinal tract diagnosed in adulthood--diagnosis and management

INTRODUCTION

Congenital anomalies of the gastrointestinal tract are a significant cause of morbidity in children and less frequently in adults. In rare cases, they may run undetected during childhood and may present during adolescence. These abnormalities include developmental obstructive defects of the duodenum and the small intestine, anomalies of rotation and fixation, intestinal duplications, and anomalies of the colon and rectum.

DISCUSSION

When detected in adulthood, they may require different evaluation and surgical correction. Some of these anomalies should be managed surgically as soon as they cause symptoms. Others may cause persistent problems in adulthood requiring medical management for years. Herein, we present a comprehensive review of all the different ways of diagnosis and management of these anomalies reported in the literature.

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Infants with intestinal malrotation present with bilious emesis and the diagnosis is generally obtained by an upper gastrointestinal barium study. Malrotation is suspected if the ligament of Treitz is not positioned to the left of the vertebral body. Three patients were admitted to our department from March 2006 to May 2007, aged three weeks, one month and eight months, weighing 3,3.200 and 8 kg respectively to whom laparoscopic Ladd's procedure was done successfully.

Congenital cardiovascular defects in children with intestinal malrotation

Intestinal malrotation (IM) and cardiovascular defects (CCVD) are both common congenital defects. We investigated the prevalence and types of CCVD in a 25-year IM population, and its association with post-IM-operative morbidity and mortality. Data on the type of CCVD, other congenital defects, syndromes, associations, post-IM-operative morbidity and mortality were retrospectively reviewed from the records of IM patients born between 1980 and 2005. Data were analyzed on (significant) differences between CCVD subgroups, and risk factors for both morbidity and mortality were calculated. Seventy-seven of 284 IM patients (27.1%) were diagnosed with a major or minor CCVD (37 and 40 patients, respectively). Syndromes and associations were more frequently diagnosed in patients with major than with a minor CCVD (67.6 vs. 40%, respectively). Post-IM-operative complications, although frequently observed (61%), did not differ between patients with major and minor CCVD. Physical CCVD signs before IM surgery increased post-IM-operative morbidity significantly (OR 4.0, 95% CI 1.4-11.0). Fifteen patients died (19.5%), seven due to cardiovascular cause. Mortality risk was increased by intestinal ischemia and post-IM-operative complications and by major CCVD after correction for age at weight at the time of IM operation. Congenital cardiovascular defects in children with intestinal malrotation are common, with high morbidity and mortality rates after IM operation. Elective IM surgery in young patients with CCVD should be performed in a centre with adequate paediatric cardiac care. Benefits of laparoscopic intervention need further study.

Surgical management of intestinal malrotation in adults

OBJECTIVE

The aim of this study was to review our experience with diagnosis and surgical management of intestinal malrotation in adult patients.

PATIENTS AND METHODS

A retrospective review of the surgical outcome of adults with intestinal malrotation was performed. Twelve patients were observed and treated between July 1996 and July 2006 (4 women and 8 men; the mean age of the patients was 28.5 years). Surgical outcomes, including postoperative complications, deaths, and resolution of preoperative symptoms, were measured.

RESULTS

A diagnosis of malrotation was made preoperatively in five patients by upper gastrointestinal contrast study, barium enema, or computed tomography scan. The anomaly was discovered incidentally at laparotomy in seven patients. All cases were proved to be malrotation intraoperatively. Nine patients underwent laparotomy and three underwent laparoscopic surgery (one converted to an open procedure). Follow-up ranged from 2 months to 118 months. Three patients had complications: one had wound infection, one had delayed gastric emptying, and one developed adhesive ileus. There were only two recurrences detected and one patient with recurrence required reoperation. No one died.

CONCLUSIONS

Intestinal malrotation is a rare but important cause of abdominal pain in adults. It may present with chronic or acute symptoms. Laparotomy and laparoscopy are alternative and feasible techniques with low rates of complications for the treatment of intestinal malrotation in adults.

Anomalies of intestinal rotation and fixation: consequences of late diagnosis beyond two years of age

The malrotation and no well fixation anomalies of the digestive tract is also frequent in older child, young and adult, with characteristic and specific clinical presentation. Actually, the diagnostic and treatment seem to be late, after suffering prolonged symptoms and/or in emergency. We present nine cases of anomalies in the embryonic development of the digestive tract which were diagnosed and treated in infants or young, all above 2 years old. Eight cases were of more or less complete intestinal malrotation; one of them was a complete malrotation with an intrinsic duodenal stenosis associated (no bands of Ladd) and another one was a right paramesocolic hernia, always accompanied by malrotation. The association with other extra-digestive anomalies, especially urological, was 70%. The predominant symptom was intermittent abdominal pain (IAP)-80%-sometimes accompanied by vomiting (35%) and episodes of diarrhoea (25%). In all the cases, while the clinical background was early, diagnosis was late. Indeed, in 60% of the cases diagnosis was made intra-operatively in emergency surgical interventions. The imaging procedures employed were scanning and Doppler ultrasound, CT scan, and contrast gastrointestinal series (GIS). Up to 30% of errors in interpretation occurred, although they were eventually corrected with other tests. The most reliable diagnostic procedures were GIS and CT scan with contrast, although partial interpretation errors occurred with the latter procedure. Surgery was essential in 80% of the pre-operative cases, and in another two it was required as a preventative measure. Post-operatively, there was notable persistence of SBS in the cases of intestinal necrosis, and of other lesser symptoms in the rest. We conclude that: intestinal malrotations and malfixations are still being diagnosed very late, with serious systemic consequences such as intestinal obstructions or necroses, and prolonged clinical suffering. This could all be avoided if more attention were paid to the digestive symptoms associated with IAP, and to subocclusion or other abdominal phenomena (distension,...), together with, in the case of doubt about the findings with the previous procedures, the opportune imaging tests (e.g., abdominal Doppler ultrasound, CT scan with contrast, and barium GIS). Unlike other authors, we consider that the morbidity/mortality associated with cases of late diagnosis of these anomalies is high, and calls for earlier surgical treatment.

Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series

Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially life-threatening complication. An evaluation for malrotation is part of every upper gastrointestinal (GI) tract examination in pediatric patients, particularly neonates and infants. Although the diagnosis of malrotation is often straightforward, the imaging features in approximately 15% of upper GI tract examinations are equivocal and lead to a false-positive or false-negative interpretation. The clinical manifestations and upper GI tract findings of malrotation in older children and adults are less specific than are those in younger patients, and for this reason diagnosis of the condition may be more difficult. Successful differentiation between a normal variant and malrotation requires the use of optimal techniques in acquiring and interpreting the upper GI series. Familiarity with the upper GI series appearance of both normal and abnormal anatomic variants allows the radiologist to increase both diagnostic accuracy and confidence in the diagnosis of malrotation.

Surgical intervention of intestinal malrotations in paediatric patients without other congenital anatomical abnormalities: Overview from a single center

The subject of malrotation in infants and children without other congenital anatomical abnormalities is reviewed from the perspective of experience with 97 patients operated in 11 years. Fifty-five patients were younger than 6 weeks at operation. They often presented with bilious vomiting, in contrast to older children who presented with non-bilious vomiting or feeding problems. Patients younger than 6 weeks were operated more often acutely than older patients. Volvulus was more common in infants younger than 6 weeks. Two patients with a resulting short bowel syndrome died. In 73 of the surviving 95 (76.8%) children their symptoms disappeared. In the children younger than 6 weeks persisting abdominal problems were significantly less frequent than in older children. In the children presenting with proven gastro-esophageal reflux disease before the malrotation operation, abdominal problems persisted significantly more often. Although there remains considerable controversy over how older children without signs of vascular problems should be managed, failure to respond to radiographic evidence of malrotation could be considered malpractice if volvulus was to occur subsequently. For this reason, every patient with a radiological proven malrotation merits diagnostic laparoscopy.

The optimal management of malrotation diagnosed after infancy: a decision analysis

BACKGROUND

The benefit of a prophylactic Ladd's procedure in older children and adults with malrotation is controversial. The purpose of this study was to determine the role of the Ladd's procedure in patients with asymptomatic malrotation diagnosed after infancy.

METHODS

A Markov decision analysis was used to compare the quality adjusted life expectancy with and without a Ladd's procedure among patients with asymptomatic malrotation. Data obtained from the Nationwide Inpatient Sample were used to estimate the age-related probability of emergency surgery or volvulus among patients with malrotation. Estimates of the mortality of elective and emergency surgery, mortality of volvulus, and utilities of each health state were obtained from the literature.

RESULTS

After infancy, the gain in quality adjusted life expectancy associated with a prophylactic Ladd's procedure was highest when asymptomatic malrotation was treated at 1 year old and steadily declined until asymptomatic malrotation was treated at 20 years old. An increasing advantage of observation over prophylactic surgery on life expectancy was observed after the second decade of life. A 2-fold increase in mortality risk for an elective Ladd's procedure decreased the age threshold to 14 years, whereas a 4-fold increase decreased the threshold to 7 years. These results were found to be robust by sensitivity analyses and Monte Carlo simulation.

CONCLUSION

A Ladd's procedure should be considered for children diagnosed with asymptomatic malrotation, particularly those who are younger and with a low risk of postoperative mortality. The rare occurrence of midgut volvulus does not justify performing a prophylactic Ladd's procedure on most adults with malrotation.

Long-term complications following intestinal malrotation and the Ladd's procedure: a 15 year review

BACKGROUND

It is accepted that children with volvulus require urgent surgery. However the long term sequelae and late complications of its surgical therapy are less well understood. We hypothesised that the surgical corrected intestinal malrotation have significant long term impact on the patients quality of life.

METHODS

Forty-six children with intestinal malrotation were operated on at a tertiary referral centre over a fifteen year period. Their charts were retrospectively reviewed and the patients were contacted.

RESULTS

The study revealed two distinct groups, those without complications 25 (54%) and those without 21 (46%). In the acute post operative period four (9%) patients had on going feeding difficulties and one (2%) developed chronic abdominal pain. However 12 (26%) required readmission within the first six months after the initial operation. Eleven (24%) patients were readmitted with acute bowel obstruction. Six (13%) patients required multiple admissions due to small bowel obstruction and six (13%) patients underwent further surgery for adhesion related obstruction. There were four (9%) deaths in the study group, three due to other medical conditions and one following small bowel obstruction. There was zero mortality immediately after the primary operation. There was no significant difference in the initial presentation, age and operative findings in those requiring further surgery and those who did not.

CONCLUSIONS

We demonstrated that there is a significant long-term morbidity associated with intestinal malrotation even after corrective surgery. Detailed education about the potential for small bowel obstruction must be given to the parents of these children.

Familial malrotation: report of three affected siblings

We herein report the case of three siblings presenting with intestinal malrotation. Their medical history and circumstances of diagnosis are described. Barium meal demonstrated a minor duodenal anomaly in the mother. As far as we can ascertain, this is the third report of isolated familial malrotation in more than one generation, raising questions about its developmental mechanism. We thus highlight in what circumstances familial investigations should be undertaken in case of malrotation.