Intestinal Malrotation in Children: Clinical Presentation and Outcomes

INTRODUCTION

 Intestinal malrotation (IM) is characterized by abnormal intestinal rotation and fixation predisposing to a risk of midgut volvulus. The aim of this study was to describe the clinical presentation and outcome of IM from birth through childhood.

MATERIALS AND METHODS

 This was a retrospective study of children with IM managed at a single center between 1983 and 2016. Data were retrieved from medical records and analyzed.

RESULTS

 Three hundred nineteen patients were eligible for the study. Using strict inclusion and exclusion criteria, 138 children were included. Vomiting was the most common symptom up to 5 years of age. At 6 to 15 years of age, abdominal pain was the predominant symptom. One hundred twenty-five patients underwent a Ladd's procedure and of 124 patients with available data, 20% had a postoperative complication (Clavien-Dindo IIIb-V) within 30 days. The odds ratio to develop postoperative complications was significantly increased in extremely preterm patients (p = 0.001) and in patients with severely affected intestinal circulation (p = 0.006). Two patients had intestinal failure due to midgut loss after midgut volvulus, one of whom needed intestinal transplantation. Four patients, all extremely preterm, died related to the surgical procedure. In addition, seven patients died of reasons not related to IM. Fourteen patients (11%) had adhesive bowel obstruction and one patient had recurrent midgut volvulus requiring surgical treatment.

CONCLUSIONS

 IM presents with different symptoms through childhood depending on age. Postoperative complications are common after Ladd's procedure, particularly among extremely preterm infants and patients with severely affected circulation caused by midgut volvulus.

Septic shock: an atypical complication of alimentary tract duplication

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

[Developmental disorders of the gastrointestinal tract]

BACKGROUND

Developmental disorders of the gastrointestinal tract comprise a broad spectrum of congenital malformations of different etiologies and locations from the mouth to the anus.

METHODS

The authors present the most important malformations of the gastrointestinal tract on the basis of basic and current reviews.

RESULTS

Gastrointestinal developmental disorders occur both sporadically and in connection with malformation syndromes. Symptoms are highly variable and range from postnatal emergencies to asymptomatic abnormalities, which may be incidental radiological findings. Prenatal ultrasound examinations can often identify gastrointestinal developmental disorders at an early stage. Here, fetal magnetic resonance imaging can be a useful addition to the diagnostic process. In the first few days of life, simple X‑ray overview images, supplemented by images after the administration of contrast medium, are often sufficient.

CONCLUSION

Many patients with a malformation of the gastrointestinal tract require lifelong medical care, so that not only pediatric radiologists need specific knowledge about this group of diseases.

Neonatal Intestinal Segmental Volvulus: What Are the Differences with Midgut Volvulus?

OBJECTIVE

 Intestinal volvulus in the neonate is a surgical emergency caused by either midgut volvulus (MV) with intestinal malrotation or less commonly, by segmental volvulus (SV) without intestinal malrotation. The aim of our study was to investigate if MV and SV can be differentiated by clinical course, intraoperative findings, and postoperative outcomes.

METHODS

 Using a defined search strategy, two investigators independently identified all studies comparing MV and SV in neonates. PRISMA guidelines were followed, and a meta-analysis was performed using RevMan 5.3.

RESULTS

 Of 1,026 abstracts screened, 104 full-text articles were analyzed, and 3 comparative studies were selected (112 patients). There were no differences in gestational age (37 vs. 36 weeks), birth weight (2,989 vs. 2,712 g), and age at presentation (6.9 vs. 3.8 days). SV was more commonly associated with abnormal findings on fetal ultrasound (US; 65 vs. 11.6%; p < 0.00001). Preoperatively, SV was more commonly associated with abdominal distension (32 vs. 77%; p < 0.05), whereas MV with a whirlpool sign on ultrasound (57 vs. 3%; p < 0.01). Bilious vomiting had similar incidence in both (88 ± 4% vs. 50 ± 5%). Intraoperatively, SV had a higher incidence of intestinal atresia (2 vs. 19%; p < 0.05) and need for bowel resection (13 vs. 91%; p < 0.00001). There were no differences in postoperative complications (13% MV vs. 14% SV), short bowel syndrome (15% MV vs. 0% SV; data available only from one study), and mortality (12% MV vs. 2% SV).

CONCLUSION

 Our study highlights the paucity of studies on SV in neonates. Nonetheless, our meta-analysis clearly indicates that SV is an entity on its own with distinct clinical features and intraoperative findings that are different from MV. SV should be considered as one of the differential diagnoses in all term and preterm babies with bilious vomiting after MV was ruled out-especially if abnormal fetal US and abdominal distension is present.

Analysis of abdominal adhesion using the ileostomy model

Abdominal adhesion occurs commonly in clinical practice, causing unfavorable symptoms and readmission. The ileostomy operation is a common surgical procedure and we utilized this model to evaluate abdominal adhesion. Adhesion grade score was calculated in 35 patients (Cohort 1) and subjected to correlation and receiver operating characteristic analysis. Then 98 consecutive patients (Cohort 2) who underwent ileostomy and ileostomy closure were included into a retrospective study. Logistic regression analysis was performed, and the risk of small bowel obstruction was also assessed. The time of ileostomy closure correlated with adhesion grade score in Cohort 1, justifying its use as an indicator of abdominal adhesion. All patients in Cohort 2 were then divided into the high- and low-adhesion group. A multi-variable logistic regression analysis indicated that type of surgery and peritoneum suture during ileostomy were significant factors affecting the risk of abdominal adhesion. Abdominal adhesion had the trend to prolong the length of stay postoperatively without increasing the risk of bowel obstruction. Nine patients suffered bowel obstruction, and age older than 65 significantly increased the risk. We proposed the ileostomy procedure to be a model of abdominal adhesion, and the operative time of ileostomy closure could be used as an alternative of adhesion score. Type of surgery and peritoneum suture may be risk factors of abdominal adhesion. Older age increased the risk of small bowel obstruction after ileostomy surgery.

Type II Congenital Pyloric Atresia with Desquamative Enteropathy Diagnosed Postoperatively: A Case Report

Congenital pyloric atresia (CPA) is a rare condition that presents as gastric outlet obstruction in the first few weeks of life. Isolated CPA typically carries a good prognosis but when associated with other conditions such as multiple intestinal atresia or epidermolysis bullosa (EB), the outcomes are generally poor. This report describes a four-day-old infant who presented with nonbilious emesis and weight loss in whom an upper gastrointestinal contrast study revealed gastric outlet obstruction determined to be consistent with pyloric atresia. The patient underwent operative repair via Heineke-Mikulicz pyloroplasty. Postoperatively, the patient continued to have severe diarrhea and was found to have desquamative enteropathy though had no skin findings consistent with EB. This report emphasizes consideration of CPA as a differential diagnosis for neonates presenting with nonbilious emesis and demonstrates the association between CPA and desquamative enteropathy without EB.

Gastric duplication cyst of a bifid pancreas: cause of recurrent vomiting

An infant girl first presented with recurrent episodes of non-bilious vomiting, having had five hospitalisations over the following months because of dehydration. Laboratory data showed no inflammatory response, normal pancreatic amylase, but increased lipase levels (between 67 and 425 U/L). Several abdominal ultrasound studies suggested an intestinal duplication cyst on left hypochondrium and, later, a dilated and irregular pancreatic duct. CT showed a bifid tailed pancreas and a change in the cyst's characteristics. A communication with the pancreatic duct was hypothesised, which was confirmed on MR cholangiopancreatography. On laparoscopic surgery, the cyst was confirmed to be at the end of the caudal side of the pancreatic bifid tail, having no communication with the stomach. Cystectomy with partial pancreatectomy was performed with pathological findings confirming a gastric duplication cyst originating from the pancreatic bifid tail. At latest follow-up, 4 months after surgery, she remains asymptomatic.

[Management Of Blader Exstrophy In Children At The CHU Gabriel Touré]

AIMS

To describe the clinical and evolutionary aspects of the primary closure of exstrophy at the CHU Gabriel Touré.

MATERIALS AND METHODS

This was a retrospective and prospective study carried out from January 2014 to December 2019 in all the children admitted and operated on for bladder exstrophy at the CHU Gabriel Touré.

RESULTS

We collected 35 cases of exstrophy, ie25 boys and 10 girls. The mean age at diagnosis was 4.8 months. The bladder plate was both normal and budded, ie 28.6% of cases. Plaque infection was found in 45.7%. A malformation was associated in 34.3% of cases. Primary plaque closure was achieved in all of our patients. Postoperative morbidity was 28.6% of cases and mortality 11.4% of cases.

CONCLUSION

Bladder exstrophy is a rare malformation of the urogenital sphere, its management is complex and its mortality is not null.

Rare case of upper gastrointestinal hemorrhage due to accessory spleen: A case report

RATIONALE

Upper gastrointestinal hemorrhage (UGIH) is defined as hemorrhage originating from the gastrointestinal tract proximal to the ligament of Treitz. The causes of UGIH include esophagitis, gastritis, peptic ulcers, Mallory-Weiss syndrome, and cancer. However, a rare cause of UGIH, such as an accessory spleen, may lead to serious complications if left untreated and can sometimes be very difficult to diagnose preoperatively.

PATIENT CONCERNS

An 18-year-old man was admitted to the Department of Gastroenterology of our hospital due to "repeated black stool for 2 months with aggravation, accompanied by hematemesis for 9 days." He denied any history of hepatitis, trauma, or surgery.

DIAGNOSIS

Laboratory evaluation revealed severe anemia (hemoglobin, 6.4 g/dL). Computed tomography revealed a mass measuring 127 mm in its largest dimension, located in the upper left abdomen, with varicose veins in the gastric fundus. Moreover, distended blue-purple tortuous veins were observed by gastroscopy in the gastric fundus. We believed the mass was likely an abnormally proliferating accessory spleen; however, the causes of severe anemia and gastrointestinal hemorrhage were unknown.

INTERVENTIONS

After discussion in a multidisciplinary conference, the mass was completely resected laparoscopically, and the subserosal veins in the gastric fundus were sutured using absorbable threads.

OUTCOMES

After the surgery, the patient recovered uneventfully without any complications. Clinicopathological examination showed that the mass was chronic congestive splenomegaly. Gastrointestinal hemorrhage secondary to an abnormally proliferating accessory spleen was confirmed as the diagnosis. Laboratory evaluation revealed hemoglobin at 12.1 g/dL 2 months after surgery. At the 12-month follow-up, the patient showed no recurrence of gastrointestinal hemorrhage.

LESSONS

UGIH caused by accessory spleen is extremely rare. This entity should be considered in differential diagnosis of gastrointestinal hemorrhage. Surgical intervention is necessary for timely diagnosis and treatment in case of gastrointestinal hemorrhage in critical clinical situations.

Midgut malrotation presenting with hyperemesis gravidarum: A case report

RATIONALE

Midgut malrotation is a rare congenital abnormality resulting from failure of complete intestinal rotation and subsequent fixation during early fetal development. There appeared to be no obvious symptoms in most patients, and a few patients may exhibit symptoms similar to hyperemesis gravidarum, such as nausea and vomiting. Here, we present a case of midgut malrotation presenting as hyperemesis gravidarum.

PATIENT CONCERNS

A 27-year-old woman with an intrauterine pregnancy of 27 + 6 weeks complained of severe nausea and vomiting for 2 weeks.

DIAGNOSIS

Magnetic resonance imaging showed obvious dilatation in the proximal part of the duodenum and gastric cavity and the absence of a duodenal path dorsal to the superior mesenteric artery, which was diagnosed as midgut malrotation.

INTERVENTIONS

Considering that the patient's vital signs were stable, without manifestation of peritonitis or the risks of surgery to the fetus, conservative treatment was adopted. Unfortunately, the fetus developed severe hydrocephalus at 32 weeks. The patient and her family decided to abandon the fetus, and a mid-trimester-induced abortion was performed.

OUTCOMES

The related symptoms completely disappeared after delivery, and the relevant examination after discharge also confirmed the presence of midgut malrotation without gastrointestinal discomfort within 1 year after delivery.

LESSONS

Midgut malrotation can be considered as a differential diagnosis of hyperemesis gravidarum. Conservative treatment under close monitoring is desirable in pregnant women diagnosed with midgut malrotation.

Variety Of Gastrointestinal Duplications In Children: Experience At Tertiary Care Hospital

BACKGROUND

Gastrointestinal duplication is a rare developmental anomaly that can be present anywhere along the GI tract, most often being found in ileum. The purpose of this study is to share our experience in evaluation of the presentation, investigations, management challenges and complications of patients with this very rare condition.

METHODS

This descriptive case series was conducted at the Department of Paediatric Surgery, National Institute of Child Health Karachi, Pakistan, from April 2018 to October 2019. Data was analysed with regard to age, clinical presentation, investigations, surgical procedures, site and type of lesion, histopathology, complications and outcomes.

RESULTS

A total of five patients were managed in one and half year. The patients' ages ranged from antenatally diagnosed foetus to 12 years old child. New-born who presented with antenatal diagnosis of abdominal cyst turned out to have duodenal duplication cyst. Among other four were thoracoabdominal duplication cyst, gastric duplication, jejunal duplication and ileal duplication, last two presented with perforation. Other presentations were abdominal pain, swelling and vomiting. Diagnosis was made on clinical ground, x-ray of abdomen, ultrasound and computed tomography. All cysts were resected successfully and patients remained asymptomatic till one year follow up except one patient who expired postoperatively due to liver failure.

CONCLUSIONS

Enteric duplication can present in variety of ways depending on anatomical location. Prompt diagnosis and complete excision of cyst is the aim of treatment. However, these rare types of duplication are a challenge to operating surgeons.

Neurodevelopmental outcome of patients with congenital gastrointestinal malformations: a systematic review and meta-analysis

AIM

Children with congenital gastrointestinal malformations may be at risk of neurodevelopmental impairment due to challenges to the developing brain, including perioperative haemodynamic changes, exposure to anaesthetics and postoperative inflammatory influences. This study aggregates existing evidence on neurodevelopmental outcome in these patients using meta-analysis.

METHOD

PubMed, Embase and Web of Science were searched for peer-reviewed articles published until October 2019. Out of the 5316 unique articles that were identified, 47 studies met the inclusion criteria and were included. Standardised mean differences (Cohen's d) between cognitive, motor and language outcome of patients with congenital gastrointestinal malformations and normative data (39 studies) or the studies' control group (8 studies) were aggregated across studies using random-effects meta-analysis. The value of (clinical) moderators was studied using meta-regression and diagnostic subgroups were compared.

RESULTS

The 47 included studies encompassed 62 cohorts, representing 2312 patients. Children with congenital gastrointestinal malformations had small-sized cognitive impairment (d=-0.435, p<0.001; 95% CI -0.567 to -0.302), medium-sized motor impairment (d=-0.610, p<0.001; 95% CI -0.769 to -0.451) and medium-sized language impairment (d=-0.670, p<0.001; 95% CI -0.914 to -0.425). Patients with short bowel syndrome had worse motor outcome. Neurodevelopmental outcome was related to the number of surgeries and length of total hospital stay, while no relations were observed with gestational age, birth weight, age and sex.

INTERPRETATION

This study shows that children with congenital gastrointestinal malformations exhibit impairments in neurodevelopmental outcome, highlighting the need for routine screening of neurodevelopment during follow-up.

Congenital Myenteric Hypoganglionosis

Congenital myenteric hypoganglionosis is a rare developmental disorder characterized clinically by severe and persistent neonatal intestinal pseudoobstruction. The diagnosis is established by the prevalence of small myenteric ganglia composed of closely spaced ganglion cells with sparse surrounding neuropil. In practice, the diagnosis entails familiarity with the normal appearance of myenteric ganglia in young infants and the ability to confidently recognize significant deviations in ganglion size and morphology. We review clinical, histologic, and immunohistochemical findings from 12 patients with congenital myenteric hypoganglionosis in comparison with similar data from age-matched controls and clearly delineate the diagnostic features of the condition. Practical guidelines are provided to assist surgical pathologists, who are likely to encounter this condition only infrequently. The diagnosis typically requires full-thickness intestinal biopsy as the abnormality is confined to the myenteric plexus in many patients. Immunohistochemistry for Hu C/D may be used to confirm hypoganglionosis. Reduced staining for calretinin and NeuN implicates a selective deficiency of intrinsic primary afferent neurons in this disease.

Communicating multiple tubular enteric duplication with toxic megacolon in an infant: A case report

RATIONALE

Gastrointestinal tract duplication is a rare congenial anomaly which can be found anywhere along the gastrointestinal tract. While many patients are incidentally diagnosed during operation, in some cases it can present with severe gastrointestinal symptoms. In this case report, the patient presented with signs of toxic megacolon leading to rapid aggravation of inflammatory shock.

PATIENT CONCERNS

A 49-day old male infant presented with fever, poor feeding, and severe abdominal distension.

DIAGNOSIS

Abdominal ultrasonography was done. During the examination, a foley catheter was inserted through the anus to evaluate bowel patency and enable rectal decompression. The tip of the foley catheter was located in a separate narrower tubular lumen adjacent to the distended rectum. These findings suggested possibility of a tubular duplication cyst of the rectum as the culprit for the bowel obstruction.

INTERVENTIONS

The patient underwent emergency laparotomy. Findings showed multiple tubular intestinal duplications involving the ileum, appendix, cecum, descending colon, sigmoid colon and rectum. The true lumen of the rectosigmoid colon was completely collapsed while the adjacent tubular cyst remained severely distended and stool passage was not possible. Decompression of the sigmoid colon was done with loop colostomy with both the wall of the true bowel and enteric cyst forming the colostomy orifice.

OUTCOMES

After 40 days of postoperative care, the patient was discharged with no immediate complications. Four months after the initial operation, colostomy take-down and transanal rectal common wall division was done. No complications were observed.

LESSONS

To our knowledge, this is the first case to be reported where a rare presentation of intestinal duplication resulted in an acute presentation toxic megacolon. Such emergency cases can be effectively treated with emergency surgical bowel decompression and elective common wall division.

Management of duodenal atresia associated with situs inversus abdominus: A case report

RATIONALE

Duodenal atresia in association with situs inversus abdominus is extremely rare. Care should be taken when selecting appropriate surgical methods, and caution should be exercised during the surgery to avoid misdiagnosis and mistreatment. With prompt recognition of the condition, the surgical procedure should be performed in a timely manner to achieve positive results.

PATIENT CONCERNS

A newborn affected by situs inversus abdominus associated with duodenal atresia, midgut malrotation, and volvulus.

DIAGNOSIS

Congenital duodenal atresia with situs inversus abdominis.

INTERVENTIONS

Diamond-shaped duodenoduodenostomy with appendectomy was performed, with the release of Ladd band and correction of the malrotation.

OUTCOMES

The baby boy is thriving well with no abdominal complaints at 4 years of surgical follow-up.

LESSONS

Although several theories are put forward to clarify this matter, the proper cause of duodenal atresia is not well defined. Clinical symptoms and examinations can assist diagnosis, the definitive cause should be ascertained by surgical approach. And the operating surgeon must be aware of the "mirror anatomy" to prevent unnecessary injuries. Additionally, long-term prognosis for duodenal atresia are very good, therefore, careful attention in postoperative management are important in such a case.

Recurrent Peumonia in an Infant With an Esophageal Lung

Esophageal lung is a rare variety of communicating bronchopulmonary foregut malformation with anomaolous communication between an isolated portion of respiratory tissue and esophagus. Children present in early life with recurrent cough and pneumonia. Majority of the reported cases are associated with other anomalies like tracheoesophageal fistula. We report a case of a 7-month-old girl with right sided esophageal lung who was misdiagnosed as dextrocardia with right sided pneumonitis.

Digestive Duplication: A rare cause of abdominal mass in an infant

INTRODUCTION

Intestinal duplications are rare malformations and hail sites are the most common. Today, the diagnosis is made in antenatal because of the performances of antenatal ultrasound.

OBSERVATION

This was a 15-month-old male infant received for constant crying, vomiting and increased abdominal volume that had been evolving for two weeks. An abdominal ultrasound was performed and objectified an intraperitoneal cyst formation of 30 x 27 mm, surrounded by a stratified wall and contiguous to a digestive loop. Surgery was performed and confirmed the existence of non-communicating ileal duplication.

CONCLUSION

Intestinal duplication is a rare malformation. Ultrasound is often sufficient for diagnosis based on the presence of a characteristic double-walled cystic mass.

Malignant neuroendocrine tumour in an adult female diagnosed with Currarino syndrome

Currarino syndrome is a rare, autosomal dominant condition of caudal anomalies, usually diagnosed in childhood. Adult presentation is rare and malignant transformation of the associated presacral mass even more so. We report a case of a 60-year-old female diagnosed with a malignant neuroendocrine tumour in the presacral mass in Currarino syndrome and describe the surgical management and pathological findings.

Diagnosis and treatment of pancreas divisum: A literature review

BACKGROUND

Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum.

DATA SOURCES

We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum.

RESULTS

There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure).

CONCLUSIONS

Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.

Traumatic perforation of a juxtapancreatic enteric duplication cyst: a paediatric emergency

This report outlines a rare case of juxtapancreatic duplication cyst in a 5-month-old infant who presented with peritonitis, secondary to traumatic perforation of the cyst. We aim to highlight the role of selective mucosectomy in these cases.

A case of an absent gall bladder presenting as biliary colic in a tertiary care hospital in Karachi

Gallbladder agenesis is a rare congenital anomaly occurring in 10-65 per 100,000 populations with the incidence being more common in females with a ratio of 3:1. Although asymptomatic, some patients present with symptoms like biliary colic and often indistinguishable from common conditions leading to unnecessary surgery. A 19-year old woman presented to the hospital with epigastric and right upper quadrant pain, other signs and symptoms consistent with biliary colic. However, on laparoscopy gall bladder was absent. Ultra-sound of the abdomen is the preferred for gallbladder diseases but due to scarcity of reports on gallbladder agenesis, it is often misread due to periportal tissue and sub-phrenic folds often reported as gallbladder or calculi leading to unnecessary surgery. Agenesis, a rare anomaly, poses a diagnostic dilemma to surgeons as it is usually diagnosed during a laparoscopic cholecystectomy. Clinicians should keep in mind this entity when the gallbladder is poorly visualized on ultrasound and think of more detailed investigations such as Magnetic resonance cholangiopancreatography.

Reoperation after Ladd's procedure in the neonatal period

AIM OF THE STUDY

To investigate (1) the indications for reoperation after neonatal Ladd's procedure, (2) the type of reoperation and (3) its outcome.

METHODS

We reviewed all neonatal Ladd's procedures in our hospital from 2003 to 2017 and the outcomes of reoperation in these patients.

MAIN RESULTS

252 neonates had Ladd's procedure: 59 were laparoscopic (23.4%) and 193 open (76.6%). 15 (6.0%) required reoperation with no difference between laparoscopic and open (p = 0.12). Overall, the indications for reoperation were: adhesive intestinal obstruction (n = 10, 4.0%), recurrent midgut volvulus (n = 4, 1.6%), and missed diagnosis of associated anomaly (n = 1, 0.4%). The incidence of recurrent midgut volvulus was higher after laparoscopic Ladd's procedure (3/59; 5.1%) compared to open Ladd's procedure (1/193; 0.5%) (p = 0.04). Adhesive intestinal obstruction developed after both open (8/193, 4.1%) or laparoscopic Ladd's procedure (2/59, 3.3%). The duration of reoperation and the length of post-operative hospital stay were 63.4 ± 27.1 min and 10.1 ± 5.2 days, respectively. After reoperation, there were no post-operative complications. All children were well at follow-up (6 months-14 years).

CONCLUSIONS

In neonates, laparoscopic Ladd's procedure compared to the open Ladd's procedure is associated with a significantly higher risk of recurrent volvulus. The risk of developing this potentially dangerous complication after laparoscopic Ladd's procedure raises doubts about the effectiveness and safety of the laparoscopic approach in neonates.

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.

Annular pancreas in China: 9 years' experience from a single center

To summarize the clinical characteristics, diagnosis, treatment and prognosis among 152 children with annular pancreas (AP). A retrospective review of 152 patients with AP who were treated with surgical repair between January 2009 and August 2017 was performed at our pediatric surgical units. Presenting symptoms, birth weight, radiological findings, associated anomalies, the type of surgery performed were analyzed. (1) 152 patients were identified, out of which 82 were males, and 70 were females; (2) the average birth weight of children with AP was less than that of healthy newborns. The birth weights of 5.4% premature infants were less than 1500 g; the birth weight of 17% full-term infants, 69% premature infants and 50% post-term infants were less than 2500 g. (3) 100 (66%) patients presented symptoms during neonatal period and 43 (28%) patients had duodenal obstruction diagnosed by prenatal ultrasound scan. (4) All cases were managed surgically by open laparotomy, and all patients were duly discharged. AP most commonly presents symptoms in early neonatal period. Infants with AP are associated with a higher rate of low birth weight, and it was because swallowed amniotic fluid could not be absorbed and impaired insulin secretion caused by abnormal pancreas. Ultrasonography, abdominal plain film and upper gastrointestinal series (UGI) are helpful, but cannot make the diagnosis, and surgery is the only effective way to diagnose and treat AP.

Double simultaneous intussusception caused by Meckel's diverticulum and intestinal duplication in a child

Intussusception is common in children. Double simultaneous intussusception is a peculiar variety of intussusception with only 14 previously reported cases. We report a unique case of a child who suffered from double simultaneous intussusception with two lead points (Meckel's diverticulum and intestinal duplication). The patient was successfully treated with manual reduction along with resection of Meckel's diverticulum and intestinal duplication. The child recovered well.

Enteric duplication cyst as a cause for small bowel obstruction in adulthood

We report a case of a patient presenting with small bowel obstruction secondary to an enteric ileal duplication cyst. Although common in infancy, they are rarely seen in adults. Radiologically they may be difficult to distinguish from a Meckel diverticulum and often the diagnosis is made retrospectively. Optimal management of the asymptomatic adult is unclear.

Worsening anemia associated with volvulus in a stable neonate with intestinal obstruction

Intrauterine intestinal obstruction complicated by midgut volvulus is a serious life-threatening diagnosis. Immediate surgical intervention is generally the course of action upon diagnosis to prevent morbidity and mortality. We report a case of intrauterine intestinal obstruction where the neonate then presented with an unusual onset of volvulus within the first 12 hours of life. The patient was born with generalized edema, a distended abdomen, and pallor. Unlike many cases, the patient did not present with typical signs of volvulus. Diagnostic imaging preceding delivery and the stable postnatal clinical course did not offer a justification for immediate laparotomy. Less than 24 hours later, the patient's hemoglobin significantly dropped leading to an emergent laparotomy. Findings included a volvulus of the terminal ileum and large amounts of intraluminal blood. Our case report includes an analysis of clinical observations that should be considered so that patients presenting with similar signs receive earlier surgical intervention.

Gastrointestinal causes of sudden unexpected death: A review

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

Complicated Gastric Duplication Cyst in an Adult Patient: Uncommon presentation of an uncommon disease

Gastric duplication cyst is a very rare congenital anomaly accounting up to 4% of all gastrointestinal tract duplications. It is a quite rare anomaly in adults, the majority of the cases are diagnosed in the neonatal period. Gastric duplication cysts are usually asymptomatic or they do present with non-specific symptoms. They are usually discovered incidentally during endoscopy or laparotomy or very rarely after getting complicated. We describe herein, along with literature review, a case of an adult patient who presented with abdominal pain and bloody vomiting and turned out to have a gastric duplication cyst complicated by internal bleeding.

Intestinal obstruction due to congenital malrotation complicating a multiple pregnancy: A rare case report

Intestinal obstruction due to congenital intestinal malrotation is usually diagnosed in neonates but may, in rare cases, occur during pregnancy. The absence of specific symptoms in combination with its low incidence makes timely detection of intestinal malrotation-related obstruction difficult in expectant mothers. We present a rare case of a 23-year-old woman with a twin pregnancy following in vitro fertilization-embryo transfer (IVF-ET) who presented with symptoms of intestinal obstruction at 22+4 weeks of gestation. This diagnosis was not confirmed by imaging and the patient was managed conservatively. Following caesarean section, she gave birth to two healthy full-term infants. During the operation, malposition of the bowel and the typical Ladd's band confirmed intestinal malrotation. This is the first report of a congential malrotation complicating a multiple pregnancy, and highlights that malrotation without volvulus can be managed conservatively.

A rare case of perforation of the subhepatic appendix by a toothpick in a patient with intestinal malrotation: laparoscopic approach

Foreign body ingestion is not an uncommon problem in clinical practice. While most ingested foreign bodies pass uneventfully through the gastrointestinal tract, sharp foreign bodies such as toothpicks should cause intestinal perforation. We reported the case of a perforation of the appendix caused by a toothpick, which also pierced the liver without hepatic damages, in a male with an intestinal malrotation and subhepatic appendix. The patient was admitted to our hospital for abdominal pain in the right upper quadrant. An abdominal computed tomography scan revealed the anomalous position of the first portion of the large intestine with inflamed appendix. A laparoscopic appendicectomy and the exploration of the abdominal cavity was performed using minimally invasive technique.

[A Case of Ascending Colon Cancer with Intestinal Malformation Treated via Laparoscopic Surgery]

A 66-year-old man attended a health check-up after a positive fecal occult blood test. Colonoscopy revealed a 2 cm type 2 lesion near the ascending colon and the upper lip ofBauhin 's valve. Contrast-enhanced computed tomography ofthe abdominal region revealed aplasia ofthe ligament ofTreitz, with the duodenum running through the center. Three-dimensional vascular construction revealed intestinal malrotation, in which the superior mesenteric artery was present on the right side of the superior mesenteric vein. A diagnosis ofascending colon cancer(T2N0M0, cStage I )was made, and a laparoscopic ileocecal resection was performed. The ascending colon was not fixed to the abdominal wall, and the colon was widely depressed within the pelvis. Because no adhesion was noted, vascular processing was performed after converting to extracorporeal manipulation via a small incision in the umbilical region. The controlling vessel was the ileocolic artery, and D2 dissection was performed. The patient suffered no postoperative complications and was discharged on hospital day 13. Most reports ofintestinal malrotation concern pediatric patients, and reports ofadult cases are relatively rare. The intestinal malrotation was confirmed intraoperatively, and the procedure was performed safely. This suggests that if intestinal malrotation can be confirmed, laparoscopic surgery can be safely performed.

Recurrent acute pancreatitis in bowel malrotation

OBJECTIVE

Recurrent acute pancreatitis is an uncommon diagnosis in teenagers. Excluded alcohol and biliary stones, more prevalent aetiologies in these group of patients are genetic pancreatitis, pancreatic duct system abnormalities, neoplasia, traumas and congenital abnormalities of the duodenum such as duodenal duplication or diverticulum. Two reported cases of recurrent pancreatitis associated to midgut malrotation were described in English literature. Bowel malrotation is a difficult diagnosis in a teenager or a young adult and a common delay is documented. Ladd's procedure is largely recognized to be the standard treatment for a symptomatic malrotation.

CASE REPORT

Our Report describes in details a case of recurrent pancreatitis, where a late diagnosis of midgut malrotation was obtained and an endoscopic management was attempted. A literature review and an analysis of two previously reported cases were performed to explore a possible aetiopathogenesis of the recurrent acute pancreatitis in patients with midgut malrotation.

RESULTS

24 months of follow-up showed an asymptomatic patient on a free diet, with a mild deranged Liver Functional Tests and a normal Amylase and Lipase. The recurrence of acute pancreatitis has not been observed until the present day.

CONCLUSIONS

Recurrent episodes of acute pancreatitis in young adults, without a history of alcohol abuse or evidence of gallstones, might be an atypical presentation of midgut malrotation and it should be in the differential diagnosis. In this case, a Ladd's operation is beneficial and an endoscopic procedure does not obtain advantages.

Recurrent acute pancreatitis caused by pancreatic biliary maljunction due to long common channel

The pancreatic biliary maljunction is a rare anomaly that affects mainly females, defined as an anatomical maljunction of the pancreatic duct and the biliary duct confluence, and may be a rare cause of recurrent acute pancreatitis. In order to early diagnosis and prompt treatment, ERCP has an important role in it.

Malrotation syndrome resulting in fatal ileus in children

BACKGROUND

This report deals with two deaths of children involving intestinal volvulus, i. e. a pathological knotting and twisting of the mesenterial root on the basis of congenital malrotation followed by obstruction and extensive ischaenia.

CASE REPORTS

(1) A 10-year-old girl (premature, 25th week) with severe disability, amaurosis and epilepsy was admitted to hospital due to general agitation and a bloated abdomen without peristaltic sounds, but died some hours later. Autopsy revealed a volvulus of 2/3 of the small intestine based on congenital malrotation with additional clamping of the intestine underneath adhesions (previous appendectomy). The abdominal cavity showed beginning peritonitis as the cause of death. (2) A 2-month-old premature male baby (surviving twin, 29th week) with a persisting ductus arteriosus was hospitalised for four weeks after failed vascular surgery due to acute general deterioration. Radiological diagnostics using a contrast medium revealed a vascular anomaly (right-sided aortic arch). Around 10 hours later, the infant developed an acute abdomen with ileus symptoms. Emergency surgery showed infarction of the entire small intestine due to an anti-clockwise 180⁰-volvulus, with death occurring 24h later. Further examination showed a malrotation as anomaly. Apparently, the volvulus had been caused by extensive use of contrast medium resulting in increased intestinal mobility.

Accessory Lobe of Liver Associated with a "Bean Shaped" Gall Bladder

Occurrence of accessory lobes of liver and anomalies of gall bladder is quite common. A thorough knowledge of their variation can minimise diagnostic and surgical errors. We found concurrent variations of liver and gall bladder. A small accessory liver lobe was attached to the quadrate lobe through a stalk formed by peritoneum. The gall bladder was "bean shaped" due to the presence of a constriction in the middle of its body. Since the accessory lobe was quite close to gall bladder, it could compress the gall bladder and hinder normal functioning of it. The knowledge of these variations might be of importance to radiologists and surgeons dealing with the hepatobiliary system.

Gastroesophageal reflux and congenital gastrointestinal malformations

Although the outcome of newborns with surgical congenital diseases (e.g., diaphragmatic hernia; esophageal atresia; omphalocele; gastroschisis) has improved rapidly with recent advances in perinatal intensive care and surgery, infant survivors often require intensive treatment after birth, have prolonged hospitalizations, and, after discharge, may have long-term sequelae including gastro-intestinal comorbidities, above all, gastroesophageal reflux (GER). This condition involves the involuntary retrograde passage of gastric contents into the esophagus, with or without regurgitation or vomiting. It is a well-recognized condition, typical of infants, with an incidence of 85%, which usually resolves after physiological maturation of the lower esophageal sphincter and lengthening of the intra-abdominal esophagus, in the first few months after birth. Although the exact cause of abnormal esophageal function in congenital defects is not clearly understood, it has been hypothesized that common (increased intra-abdominal pressure after closure of the abdominal defect) and/or specific (e.g., motility disturbance of the upper gastrointestinal tract, damage of esophageal peristaltic pump) pathological mechanisms may play a role in the etiology of GER in patients with birth defects. Improvement of knowledge could positively impact the long-term prognosis of patients with surgical congenital diseases. The present manuscript provides a literature review focused on pathological and clinical characteristics of GER in patients who have undergone surgical treatment for congenital abdominal malformations.

Abnormal layering of muscularis propria as a cause of chronic intestinal pseudo-obstruction: A case report and literature review

Visceral myopathy is one of the causes of chronic intestinal pseudo-obstruction. Most cases pathologically reveal degenerative changes of myocytes or muscularis propia atrophy and fibrosis. Abnormal layering of muscularis propria is extremely rare. We report a case of a 9-mo-old Thai male baby who presented with chronic intestinal pseudo-obstruction. Histologic findings showed abnormal layering of small intestinal muscularis propria with an additional oblique layer and aberrant muscularization in serosa. The patient also had a short small bowel without malrotation, brachydactyly, and absence of the 2^nd to 4^th middle phalanges of both hands. The patient was treated with cisapride and combined parenteral and enteral nutritional support. He had gradual clinical improvement and gained body weight. Subsequently, the parenteral nutrition was discontinued. The previously reported cases are reviewed and discussed.

[Surgical treatment of rare combination of intestinal malrotation with secondary lymphangiectasia]

The rare combination of intestinal lymphangiectasia with malrotation of the duodenum in a child of three months of life is described. Basing on the literature review only 3 similar cases were described in the world practice. The boy with protein-losing enteropathy was examined at Moscow Scientific Centre of Children's Health. The child had vomiting, diarrhea, loss in body weight, hypoproteinemia, lymphopenia. The infectious nature of the disease was excluded. It had been suggested the Waldman desease (primary intestinal lymphangiectasia). The prognosis for such disease is unfavorable. An examination of the child was continued against the backdrop of ongoing symptomatic therapy. Complete physical examination included monitoring laboratory blood tests, X-ray examination with contrast, CT-scan, gastroduodenoscopy with biopsy of the mucosa of the small intestine. Malrotation duodenum with the recurrent mid-gut volvulus with the development of secondary intestinal lymphangiectasia was diagnosed. Modern methods of examination and multidisciplinary approach made it possible to diagnose the case. Operation to eliminate fixation duodenum resulted in the recovery of the patient. At the present time the child grows and develops according to age and does not require treatment. The prognosis for this disease is regarded as favorable.

Congenital left intrahepatic bile duct draining into gastric wall mimicking biliary reflux gastritis

Abnormalities and variations of the biliary ducts are not rare. Most aberrant bile ducts eventually drain into the descending part of duodenum through the papilla of vater. However, drainage of the left hepatic bile duct into the stomach is extremely rare. A 29-year old man was admitted to the hospital with the diagnosis of biliary reflux gastritis. Comprehensive imaging modalities were performed including electronic endoscopy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangio-pancreatography. Finally, congenital ectopic left intrahepatic bile duct draining into the stomach was found, which caused biliary reflux gastritis. The patient did not receive any surgery. Good recovery was achieved by medical treatment.