Ladd Procedure Research Articles

Retrospective Cohort Study of Associated Factors for Intestinal Complications in Pediatric Liver Transplantation.

Intestinal complications (IC) represent serious adverse events after liver transplantation (LT), however limited research has been conducted in pediatric cohorts. This study aims to describe IC after pediatric LT and to identify associated factors. Retrospective review of 153 patients having undergone LT, aged 0-18 years, treated in the Swiss Pediatric Liver Center in Geneva. Pre-, per- and postoperative data were analyzed. IC were defined as pathologies or lesions directly associated with LT and attributable to the surgical procedure. 16/153 (11%) patients developed IC: 10/16 mechanical obstructions, 4/16 intestinal perforations and 2/16 sub-mesocolic abscesses. IC patients had a significantly lower Body Mass Index (BMI) (15.5 vs. 16.4, p = 0.019). Children with IC had significantly higher incidence of previous Kasai hepatoportoenterostomy associated with Ladd procedure (13% vs. 2%, p = 0.055), a history of intraoperative iatrogenic intestinal perforation(s) (31% vs. 5%, p = 0.003) and prolonged LT surgery duration (536 vs. 415 min, p = 0.007). Significantly more children with IC had received basiliximab (69% vs. 40%, p = 0.048). Patients with IC exhibited a higher incidence of post-LT sub-occlusions (p < 0.001) and an increased requirement for post-LT parenteral nutrition (p = 0.027). Additionally, IC patients underwent significantly more reoperations (p < 0.001). One in 10 children post-LT experiences IC, which are associated with significant morbidity. Pre-LT nutritional status appears as an associated factor with IC, along with the necessity for adhesiolysis during LT, often leading to prolonged operative time. These associated factors should alert medical teams to promote early IC diagnosis in patients after LT.

Delayed Diagnosis of Volvulus without Complications in Pediatric Patient : A Case Report

Introduction: Volvulus in children is rare occurrence, it’s only about 3-5% cases in worldwide. Without abdominal radiological examination, it is difficult to make diagnosis of volvulus based on history and physical examination alone. The management procedures are also controversial, as some recommend a non-operative approach, while others recommend an operative approach in the form of Ladd's Procedure or laparoscopy. Sigmoidoscopy or a barium enema can be attempted as an initial treatment for sigmoid volvulus. Objective: The purpose of this case report is to discuss why there was a delay in diagnosis of volvulus in this case and how to deal it. It also discusses the approach to diagnosis and management of volvulus in pediatric patients, both at the primary health center and the hospital, and why in this case. Case presentation: In this case, volvulus occurred in a pediatric patient who had sought treatment at a primary health center with a complaint of abdominal pain for nine days without improvement. The complaint was accompanied with constipation and fever. Due to limited facilities in primary health center, the patient was referred to the hospital. Result: At the hospital, after taking the history, performing physical examination, and conducting radiological examination and laboratory tests, the patient was diagnosed with ileus obstruction due to volvulus. Conclusion: Although volvulus is a rare case, volvulus should still be included as a differential diagnosis of abdominal pain in pediatric patients to avoid delayed diagnosis. Delay in diagnosis and management of volvulus can lead to serious complications and even life-threatening conditions

A case of isolated malrotation without midgut volvulus diagnosed prenatally and treated by laparoscopic surgery

BackgroundMalrotation is a congenital condition that predisposes individuals to midgut volvulus, which can result in significant bowel resection. While most cases of malrotation are diagnosed by the age of 1 year, typically presenting with symptoms related to volvulus or bowel obstruction, some cases remain asymptomatic. In children with visceral malposition, gastroschisis, omphalocele, or diaphragmatic hernia, malrotation may be suspected before symptoms manifest. However, isolated malrotation without midgut volvulus diagnosed prenatally is rare. We herein present a case of isolated malrotation without midgut volvulus that was prenatally diagnosed and successfully treated with laparoscopic surgery.Case presentationA 30-year-old woman (gravida 3, para 1) underwent routine obstetric ultrasound, which revealed increased blood flow in the lower uterine segment and abnormal placental attachment. To rule out placenta percreta, magnetic resonance imaging was performed at 34 weeks of gestation. Incidentally, abnormal fetal intestinal arrangement was noted, with the colon localized in the left hemi-abdomen and the small intestine distributed in the right hemi-abdomen, raising suspicion of malrotation. Postnatal contrast studies confirmed the diagnosis of malrotation without midgut volvulus. Given the risk of midgut volvulus, a laparoscopic Ladd’s procedure was performed on day 6 of life. The postoperative course was uneventful, and the patient was still symptom-free 1 year postoperatively.ConclusionsThis case illustrates that malrotation can be prenatally diagnosed using fetal magnetic resonance imaging. Considering the risk of midgut volvulus, prophylactic Ladd’s procedure should be performed in neonatal period. In cases where malrotation is not complicated by midgut volvulus, a laparoscopic Ladd procedure can be safely performed in neonates.

Mesenteric Base Width: Abdominal Wall Diameter Correlates With Intestinal Rotational Anomalies in Infants

IntroductionSymptomatic malrotation requires urgent Ladd procedure. Patients with incidental or indeterminate findings have historically been managed with observation or operatively. Fluoroscopic identification of the duodenojejunal junction (DJJ) and ileocecal junction (ICJ) can guide operative decision-making, but algorithms have not been validated. This study aimed to determine whether fluoroscopic mesenteric base width (MBW) standardized to abdominal wall diameter (AWD) correlates with intraoperative anatomy in infants. MethodsWe retrospectively reviewed patients between 2013 and 2023 who were <1 year with fluoroscopy identifying DJJ and ICJ. Infants with normal rotation evaluated for digestive concerns were included. Congenital conditions with intestinal nonrotation were excluded. Two radiologists independently measured MBW as a diagonal line from DJJ to ICJ and maximal transverse AWD from inferior ribs. A ratio was calculated and compared between groups. Wilcoxon rank-sum and Kruskal–Wallis tests with p < 0.05 were considered significant. Area under the receiver operating characteristic curve (AUROC) was used to identify optimal ratio cutoff. ResultsFifty-eight patients, 22 normally rotated and 36 with intestinal rotational abnormality (IRA), met inclusion criteria. Preoperative radiographic concern for malrotation differed between groups (p < 0.0001). Median MBW:AWD was significantly lower in IRA than normal rotation based on imaging (0.31 vs 0.65, p < 0.0001). Optimal MBW:AWD of 0.55 had an AUROC of 0.9578. ConclusionsRadiographic measurement of MBW:AWD accurately predicted IRA from normal rotation with an optimal ratio cutoff of 0.55. Further validation will determine whether this ratio should play a role in management of incidental IRA or indeterminate findings on UGI. Level of EvidenceIII.

Delayed Presentation of Malrotation after Infancy: A Systematic Review Based on Clinical Presentations, Associated Anomalies, Diagnosis, and Management.

Approximately 75% of patients with classic malrotation and midgut volvulus present in neonatal age-group; another 15% may present up to one year. In these, the diagnosis is made because of typical presentation. However, there are many cases in which malrotation has been detected after infancy. In-spite of the variable case reports and studies in literature, there is no specific data on the incidence of malrotation after infancy, its presentation and management guidelines. With this systematic review, we aim to coalesce these findings from various individual case reports and studies. This systematic review was performed as per the PRISMA (preferred reporting items for systematic review and meta-analyses) guidelines. The authors conducted thorough searches in databases like PubMed/MEDLINE, SCOPUS, Google Scholar and Web of Science for relevant articles. Studies were reviewed for clinical presentation and outcome for malrotation diagnosed beyond infancy. Clinical presentation of malrotation after infancy can be acute as well as chronic; acute presentation being common under 2 years of age and chronic symptoms present as age increases. Sudden onset of abdominal pain and bilious vomiting are commonest acute symptoms and intermittent episodes of recurring vague abdominal pain associated with vomiting and diarrhoea are the commonest chronic symptoms. The diagnostic modalities vary from UGI Contrast series to USG with colour Doppler and CECT scan. Management is operative open as well as laparoscopic Ladd's procedure is being favoured.

Laparoscopic Versus Open Ladd Procedure for Midgut Malrotation

IntroductionIntestinal malrotation is an uncommon developmental anomaly that can lead to duodenal obstruction and midgut volvulus. The standard correctional operation, Ladd's operation, is traditionally performed using an open approach, but providers are increasingly performing the procedure laparoscopically. However, there remains concern that the reduced adhesive burden associated with laparoscopy could predispose to recurrent volvulus. MethodsWe queried our institutional database from 2012 to 2022 for patients <18 years who underwent Ladd's operation for malrotation. We analyzed baseline characteristics and outcomes including post-operative volvulus, adhesive small bowel obstruction (SBO), duodenal obstruction, and overall abdominal re-operation. ResultsWe identified 226 patients, of whom 90 (40%) underwent a laparoscopic operation. Those undergoing open surgery were younger and had a higher rate of volvulus compared to laparoscopic patients. There were no differences in surgical history or underlying comorbidities. Laparoscopic patients were less likely to develop a post-operative adhesive SBO [1/90 (1%) vs 14/136 (10.0%); OR 9.4 (1.7–176.4), p = 0.036] with no increased rate of volvulus [1/90 (1%) vs 1/136 (0.7%), p = 0.778]. However, there were four laparoscopic patients that required re-operation for a duodenal stricture or kink, which led the overall rate of abdominal re-operation to not be different [7/90 (8%) vs 16/136 (12%); OR 1.6 (0.6–4.8), p = 0.371]. Median follow up was 2.3 years [IQR 1.0–5.0]. ConclusionLaparoscopic correction of midgut malrotation demonstrates no increased risk of post-operative volvulus and may reduce the rate of adhesive SBO. These benefits must be weighed against the potential increased risk of duodenal stricture or obstruction secondary to an incomplete Ladd's procedure. Level of EvidenceIII.

Clinical management of intestinal malrotation in different age groups

PurposeIntestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation.MethodsThis retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed.ResultsThe study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus.ConclusionThe diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients.

Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure

BackgroundThe Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure. MethodsA retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL). ResultsA total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10–50), operative time was 2.3 h (IQR, 1.8–2.8), and hospital length of stay was 2 days (IQR, 2–3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25–13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition. ConclusionThe laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

Congenital Malrotation of the Midgut Presenting as Acute Duodenal Obstruction in a Teenager — A Case Report

Background: Intestinal malrotation, a congenital anomaly, typically presents in neonates with midgut volvulus. However, recent studies suggest it may occur in adolescents and adults at a higher rate than previously thought. This case report investigates the presentation and management of malrotation with volvulus in an adolescent. Case Presentation: A 14-year-old boy presented with acute onset abdominal pain, vomiting, and a history of intermittent abdominal pain for several years. Initial diagnosis was gastritis, but imaging revealed malrotation with volvulus. He underwent a successful Ladd's procedure. Conclusion: This case emphasizes that malrotation can present with chronic or acute symptoms in adolescents. A high index of suspicion for malrotation is crucial, particularly in adolescents with recurrent abdominal pain. Early diagnosis and Ladd's procedure can prevent life-threatening complications.

Identification and treatment of intestinal malrotation with midgut volvulus in childhood: a multicenter retrospective study.

Intestinal malrotation is a rare condition, and its delayed diagnosis can lead to fatal consequences. This study aimed to investigate the identification and treatment of malrotation in children. Clinical data, imaging, operative findings, and early postoperative outcomes of 75 children with malrotation were retrospectively analyzed. The mean age was 6.18 ± 4.93 days and 51.26 ± 70.13 months in the neonatal group (56 patients) and non-neonatal group (19 patients), respectively. Sixty-seven patients were under the age of 1 year at the time of diagnosis. The occurrence of bilious vomiting and jaundice was significantly higher in the neonatal group (89.29%) than that in the non-neonatal group (37.5%), p < 0.05 and p < 0.01, respectively. The incidence of abnormal ultrasound (US) findings was 97.30% and 100%, respectively, and the sensitivities of the upper gastrointestinal series were 84.21% and 87.5%, respectively. Sixty-six (88%) patients had midgut volvulus, including in utero volvulus (two patients) and irreversible intestinal ischemia (four patients). Most neonates (89.29%) underwent open Ladd's procedure with a shorter operative time (p < 0.01). Reoperation was performed for postoperative complications (four patients) or missed comorbidities (two patients). Non-bilious vomiting was the initial symptom in >10% of neonates and nearly 40% of non-neonates. This highlights the importance for emergency physicians and surgeons to be cautious about ruling out malrotation in patients with non-bilious vomiting. Utilizing US can obviate the need for contrast examinations owing to its higher diagnostic accuracy and rapid diagnosis and can be recommended as a first-line imaging technique. Additionally, open surgery is still an option for neonatal patients.

A Rare Case: Stenosis Doudeni Congenital et Causa Ladd Band Eet Causa Malrotation with Situs Inversus in 12 Days Old Baby

We are sharing a rare presentation of congenital duodenal obstruction with combined intrinsic and extrinsic causes with situs inversus, namely, duodenal stenosis with gastrointestinal malrotation in a neonate. The patient underwent successful exploratory laparotomy, Ladd's procedure, and appendicectomy were carried out. Early recognition of signs and symptoms, prompt corrective surgery, and adequate optimization of metabolic components post-operatively are important to determine the decreased morbidity and mortality of neonates.

A49 AN UNEXPECTED CASE OF SEVERE PROTEIN-LOSING ENTEROPATHY IN A TODDLER

Abstract Background Protein-losing enteropathies (PLE) are characterized by excess loss of serum proteins into the gastrointestinal tract, resulting in hypoproteinemia, peripheral edema, and related respiratory and cardiac sequelae. PLE should be suspected in patients with hypoproteinemia not explained by protein malnutrition, impaired hepatic protein synthesis, or renal losses, and can occur as a consequence of erosive or non-erosive gastrointestinal diseases, and conditions that alter lymphatic flow. Aims To present a case of intestinal malrotation with chronic volvulus presenting as PLE. Methods In this report, we describe a pediatric patient presenting with PLE ultimately found to have intestinal malrotation with chronic volvulus. Results A healthy 1-year-old male presented with acute non-bloody diarrhea and peripheral edema on a background of recurrent colicky abdominal pain and non-bilious emesis. He had significant electrolyte derangements at presentation including hypokalemia, hyponatremia, hypomagnesemia, and metabolic acidosis, with additional laboratory findings of hypoalbuminemia (11g/L), hypogammaglobulinemia (IgA 0.11g/L, IgG 0.77g/L, IgM 0.28g/L), lymphopenia (0.4x10E9/L), and fat-soluble vitamin deficiency (Vitamin A 0.5umol/L, 25-Hydroxyvitamin D 18.4nmol/L, Vitamin E 6umol/L, INR 1.7). In addition to abdominal imaging, he underwent endoscopic evaluation which did not identify an underlying etiology. As his presentation was consistent with PLE, a high-protein, low-fat diet was initiated. Despite dietary adherence for 16 weeks, the PLE features persisted with ongoing severe hypoalbuminemia (20g/L). Given a suspicion of intestinal lymphangiectasia, a capsule endoscopy was arranged. In the interim, the patient had recurrence of abdominal pain and emesis prompting a repeat abdominal ultrasound which demonstrated swirling of the mesenteric vessels in the midline. An upper gastrointestinal series identified a short mesenteric root with the duodenojejunal junction and cecum in proximity. Urgent laparotomy confirmed a 720-degree volvulus of the small bowel around the mesenteric root, with an abnormally positioned duodenojejunal flexure and cecum. This was presumed to be chronic given the absence of acute vascular compromise. The patient underwent a Ladd procedure. He had complete resolution of symptoms and PLE features on a liberalized diet. Conclusions This report identifies a case of intestinal malrotation with chronic volvulus presenting as PLE, highlighting an atypical presentation of intestinal malrotation outside the neonatal period. Awareness of these atypical presentations is important to facilitate prompt diagnosis and treatment, thereby reducing the rate of complications. Funding Agencies None

Massive Chylous Ascites in a 9-Year-Old Girl with Malrotation-A Case Report.

Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast-enhanced magnetic resonance lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body magnetic resonance imaging revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd's procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 L of fluid. She was discharged the day after surgery and has been in good health for 1 year. We present a video illustrating the Ladd's procedure steps in this patient.

Hirschsprung disease and intestinal malrotation: A rare association with unique perioperative considerations

BackgroundMultiple etiologies exist for neonatal intestinal obstruction with similar presenting symptoms. While single etiology is the most common cause, concomitant surgical diagnoses exist requiring unique peri‑operative considerations. We present a retrospective review of 5 patients with a rare association of Hirschsprung disease (HD) and intestinal malrotation. MethodsAfter IRB approval, patients were identified utilizing Data Direct and Electronic Medical Records ID with pathologically confirmed HD and intestinal malrotation from a single institution and retrospective review was performed. ResultsFive patients were identified with the concomitant malrotation and HD diagnoses over a 15-year period. Intestinal malrotation was confirmed by intra-operative findings. HD was confirmed in all patients by rectal biopsy. Feeding intolerance was the most common chief complaint. A contrast enema was the initial diagnostic test of choice in 3 of 5 of patients. All patients underwent a Ladd procedure, including appendectomy, during the index admission. Two of 5 patients underwent surgical management for HD during the index admission, while surgery was delayed in the remaining 3. ConclusionsAssociation between HD and malrotation causing intestinal obstruction has been previously described, albeit rare. The two diagnoses can present similarly in neonatal patients; although, the underlying pathophysiology, work up and surgical management is quite different. Traditionally, a Ladd procedure is performed utilizing an open approach and includes an appendectomy. However, patients undergoing a Ladd procedure with high suspicion of HD pre-operatively pose unique considerations. We present data of 5 patients to highlight unique considerations regarding diagnostic work up and operative planning.

Midgut volvulus due to congenital malrotation in an adult: a case report

BackgroundIntestinal Malrotation is congenital that complicates 1 in every 200 births. It results from abnormal fixation and rotation of the gut tube during fetal development. It is usually asymptomatic and most cases are diagnosed during childhood and the condition is seldom seen in adults. Also, it can present as an incidental finding in imaging or patients undergoing laparotomy for other reasons. Midgut Volvulus can lead to small obstruction it warrants surgical intervention.Case presentationOur case is a 20 years old black African male from Khartoum (Sudan) who presented to the emergency department with features of intestinal obstruction he was resuscitated and underwent a CT scan of the abdomen that showed malrotation of the intestine with volvulus for which he underwent a Ladd procedure.ConclusionSmall bowel obstruction due to volvulus complicating malrotation is a rare presentation in adulthood and the Ladd procedure can be utilized to manage such case.

Effect of neuromuscular block on surgical conditions during laparoscopic surgery in neonates and small infants: A randomised controlled trial.

Neuromuscular block (NMB) is routinely used in paediatric and adult anaesthesia to facilitate endotracheal intubation and optimise surgical conditions. However, there are limited data regarding NMB and optimising the conditions for laparoscopic surgery in neonates and small infants. The goal of this study was to determine the effect of NMB on the conditions for laparoscopic surgery in neonates and small infants. A randomised controlled trial. Single-centre Children's Hospital, conducted from November 2021 to December 2022. One hundred and two ASA I-II neonates and small infants aged up to 60 weeks postmenstrual age who were scheduled to undergo an elective laparoscopic Ladd's procedure were included in the study. Patients were randomised into three groups: no NMB group, shallow NMB group and moderate NMB group. Each group was given different doses of rocuronium to achieve the target depth of NMB. The primary outcome was the quality of the surgical conditions evaluated with the Leiden-Surgical Rating Scale (L-SRS) by a blinded surgeon. Secondary outcomes included tracheal intubating conditions and adverse events. The percentage of L-SRS scores of 4 or 5 was similar among the three groups at all the assessment times (P > 0.05 for each time interval). The distribution of L-SRS scores was also similar among the three groups. There were no significant differences in operating condition scores between the groups at any time interval (P > 0.05 for each time interval). The incidence of adverse events during anaesthesia induction was significantly higher in the no NMB group (51.4%) than in the other two groups (13.6% and 14.7%) (adjusted P = 0.012 and adjusted P = 0.003). In particular, clinically unacceptable intubation conditions occurred in 12 patients (34.3%) in the no NMB group, significantly more than in the shallow NMB group (6.1%, adjusted P = 0.012) and moderate NMB group (2.9%, adjusted P = 0.003). There was no statistically significant difference in the incidence of adverse events in the PACU among the three groups (P = 0.103). The depth of NMB was not associated with superior surgical conditions during laparoscopic surgery, but it was associated with a reduction in adverse events during induction and maintenance of anaesthesia in neonates and small infants. Registered at www.chictr.org.cn (ChiCTR2100052296).

Laparoscopic Ladd's procedure for the repair of a right paraduodenal hernia in pediatric patients – A case series

Right paraduodenal hernias are a consequence of midgut malrotation resulting in small bowel encased in a peritoneal-lined hernia sac posterior to the right mesocolon. An indistinct presentation often lends a difficult clinical diagnosis and identification on diagnostic laparoscopy; however, when identified, surgical repair should ensue due to a significant lifetime risk of small bowel incarceration. Two female adolescents (ages 12 and 16-years-old) were referred to Pediatric Surgery clinic for intermittent abdominal pain and frequent emesis with radiographic and endoscopic findings consistent with intestinal malrotation. Patients underwent diagnostic laparoscopy at which time a right paraduodenal hernia was identified. Repair was performed via a laparoscopic hernia reduction and laparoscopic Ladd's procedure with appendectomy. Procedure time was 96–206 minutes. There were no intraoperative or postoperative complications to date. Both patients reported near to complete resolution of abdominal pain and emesis. Laparoscopic paraduodenal hernia reduction and Ladd's procedure with appendectomy is a novel, minimally invasive approach to the repair of right paraduodenal hernia in children.

Intestinal Malrotation in Children: Clinical Presentation and Outcomes.

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. 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. 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. 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.

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

PurposeIntestinal 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. MethodsNewborns 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. Results4797 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. ConclusionLadd 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 studyRetrospective Comparative. Level of evidenceIII.

Congenital Intestinal Malrotation in Newborns: Laparoscopic Ladds Procedure versus Open Laparotomy

To assess the efficacy and safety of laparotomic or laparoscopic Ladd's procedure in newborns with congenital malrotation. Descriptive study. Department of Pediatric Surgery, Ganzhou Maternal and Child Health Care Hospital, Ganzhou JiangXi province, China, from January 2015 to December 2021. The clinical data of newborns with malcorrection were retrospectively analysed. Patients were divided into laparotomy group (64 cases) and laparoscopy group (30 cases), according to the surgery they had been subjected. The patients who had the severe malformations, underwent the laparoscopic Ladd's procedure at the first 10 cases, and had found bowel necrosis during operation were excluded. The general data such as lengths of operation, intraoperative blood loss, time-to-diet, lengths of hospital stay, and postoperative complications were compared between the two groups. Crude comparisons showed that the laparoscopy increased the lengths of operative time (70.0 vs. 110.0 minutes, p <0.001) but decreased the postoperative complications (25.0% vs. 6.7%, p=0.035). The intraoperative blood loss, time-to-diet, and lengths of hospital stay between the two groups were not statistically significant (p=0.109, 0.065, and 0.858 respectively). The intestinal volvulus in the two groups (43.8% vs. 80.0%, p=0.001) had statistical differences. Using modified Poisson regression analysis, adjusting for confounding differences of midgut volvulus, lengths of operation time and intraoperative blood loss, and laparoscopic Ladd's showed a significant decrease in postoperative complications (RR=0.13,95%CI 0.03-0.54, p=0.005). Laparoscopic Ladd's procedure is feasible to treat neonatal malrotation and is associated with lower postoperative complications of newborns with congenital malrotation. Newborns, Congenital malrotation, Laparoscopy, Laparotomy, Complications.