Malrotation In Children Research Articles

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

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. 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. 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±1.2years) than those who underwent laparoscopy (2.6±3years; p<0.0001). Laparoscopy was converted to open Ladd's in 25.3% patients. Laparoscopy was associated with faster full enteral feeding (1.5±0.3days) in comparison to open surgery (4.6±0.1days, p<0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9±4.3days) than in the open group (11.2±6.7days; 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). 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.

Evaluating a management strategy for malrotation in heterotaxy patients

BackgroundThere is disagreement over the management of malrotation in children with heterotaxy and congenital heart disease (CHD). We sought to evaluate the outcomes of management with a Ladd procedure compared to observation in this cohort of patients. MethodsWe performed a retrospective review of CHD children with heterotaxy and malrotation identified on radiographs treated from 8/2002 until 4/2014. Primary outcomes evaluated were readmission for small bowel obstruction (SBO) or volvulus. ResultsWe identified 88 patients with cardiac heterotaxy and malrotation. Sixty-eight (77%) had a Ladd procedure. Eighteen (26%) of the 68 had abdominal symptoms, but only one had an underlying volvulus without ischemia. Twenty (23%) patients died of cardiopulmonary complications, 8 before and 12 after the Ladd procedure. Sixty-eight patients survived to the review date (median: 5years): 56 in the Ladd cohort and 12 observed. Six of the 56 (11%) surviving Ladd patients were readmitted to hospital with an SBO, and 2 required surgical intervention. None of the 12 surviving nonoperative patients developed a volvulus. ConclusionEleven percent of patients developed SBO after their Ladd procedure. Conversely, no observed patients developed a volvulus. This suggests that complications from a Ladd procedure occur with higher frequency than complications from observing heterotaxy patients with malrotation.

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

Background Atypical presentations of intestinal malrotation are more common in older children with a diagnostic and therapeutic challenge. Upper gastrointestinal (UGI) contrast study is essential for the diagnosis of the majority of cases. Recently, laparoscopy has been used in the management of malrotation. We present our experience with laparoscopic management of atypical presentations of intestinal malrotation in children, describing laparoscopic findings in these cases. Patients and methods A total of 40 patients with atypical presentations of malrotation were included in this study. The main presentations were recurrent abdominal pain, intermittent intestinal obstruction, recurrent bilious vomiting, and failure to thrive. They all were subjected to thorough history taking, clinical examination, routine laboratory investigations, and UGI contrast study. No preoperative definitive diagnosis of malrotation was performed and all patients underwent laparoscopic evaluation. Results Forty patients (25 males and 15 females) with a mean age of 7± 2.8 years were subjected to laparoscopy. Thirty-six patients (90%) were found to have definite laparoscopic findings in the form of markedly dilated stomach and first part of duodenum, ectopic site of cecum, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic ectasia, generalized mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, and rightsided small bowel and narrow mesenteric base. Four patients had differed laparoscopic diagnosis. All the procedures were completed laparoscopically. All the patients achieved full recovery without intraoperative or postoperative complications. Conclusion Laparoscopy permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. These newly described laparoscopic findings are the key for the diagnosis of malrotation with atypical presentation. Keywords : Ladd’s procedure, laparoscopy, mesenteric lymphadenopathy, undocumented malrotation

SURGICAL TACTICS FOR INTESTINAL MALROTATION IN CHILDREN

Abstract: Many aspects of surgical treatment of intestinal malrotation in children remain to be debatable. In the opinion of the majority of the specialists, surgical treatment is required after the diagnosis taking into account serious complications of intestinal malrotation.Purpose. The purpose of this research was to conduct an analysis of surgical tactics and operative treatment method for isolated and associated intestinal malrotations in children.Material and methods. We observed 123 children at the age of one day to 15 years with malrotation during the period of 2002 to 2013.Results. We presented the data from observing 123 children at the age of one day to 15 years with various clinical-anatomic forms of intestinal malrotation over from 2002 to 2013. In 62 patients (50.4%), the evidences of the high intestinal obstruction were prevalent, while 61 (49.6%) showed signs of low intestinal obstruction. 116 patients (94,3%) were given operative intervention: radical – 95(81,9%) and palliative – 21 (18,1%). In 56 % of the cases, various simultaneous surgeries were required. There are proposed differential approaches in relation to anatomic form of malrotation and possibility of the fixation of large intestine in the physiological position.Conclusion. The results obtained from the operative treatment are presented. The lethal outcomes could be reduced from 54.7%, among the patients being observed from 2002 to 2010, to 16,7% in patients being operated during 2011 to 2013.

Laparoscopic repair of malrotation: what are the indications in neonates and children?

To define the role of laparoscopy for treating malrotation in children. The Ladd procedure (9 laparoscopic [lap-Ladd], 17 open [open-Ladd]; n=26) was performed in children up to and including 30 days of age (neonatal [Group N]) and older (Group C). These groups were compared retrospectively. Group N (n=14) comprised 3 lap-Ladd and 11 open-Ladd patients. Group C (n=12) comprised 6 lap-Ladd and 6 open-Ladd patients. No case had ischemic bowel preoperatively. Intestinal volvulus was confirmed in 3 of 3 lap-Ladd and 9 of 11 open-Ladd patients in Group N, compared with 5 of 6 lap-Ladd and 6 of 6 open-Ladd patients in Group C (P=not significant). Mean operating times were significantly longer for lap-Ladd patients (130.7 minutes versus 81.1 minutes in Group N and 119.2 minutes versus 74.2 minutes in Group C). Conversion to an open-Ladd procedure was necessary in 1 of 3 patients in Group N and 1 of 6 patients in Group C (P=not significant). Complications arose in open-Ladd patients, bowel obstruction in Group N (1 of 11), and mesenteric chylorrhea in Group C (1 of 6). There was recurrence in 1 of 3 lap-Ladd patients in Group N. Mean time to recommence feeding was earlier for lap-Ladd patients (P=not significant). Length of hospitalization was similar in Group N but was shorter for lap-Ladd patients in Group C (P=not significant). Although lap-Ladd appears to be a safe procedure, it cannot be recommended for the treatment of malrotation in neonates.

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

PurposeThe purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD). MethodsPatients 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. ResultsOf 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. ConclusionsIn patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative.

Contrast meals and malrotation in children—metal markers for improved accuracy

Upper gastrointestinal contrast studies in children may cause false-positive or -negative diagnosis of intestinal malrotation from rotation of the patient. To alleviate this problem, skin markers can be used to reduce rotation of children undergoing this procedure, e.g., two metal markers (sheathed and sealed hypodermic needles) can be fixed onto the skin for gastro-intestinal contrast studies. We reviewed two Katz criteria influenced by patient rotation: duodenojejunal junction on or to the right of the left pedicle and pylorus to the left of the midline. A test group was positioned using markers; a control group without markers was positioned conventionally. Markers during a pilot study were applied, but positioning was done by helpers who had no on-screen visualization. In the test group, only 1 child (3%; n = 39) had a feature of malrotation. In the control group, there were features of malrotation in 12 children (25%; n = 48). No other features of malrotation were seen. The pilot study showed radiographic rotation with markers projecting off the midline in 78% of 58 children. This resulted in 48% of 58 patients having false features of malrotation. The use of metal skin markers results in reduction of rotational errors that could have caused false diagnosis of intestinal malrotation in children.

704 Malrotation - Not a Laughing Matter

BackgroundEarly diagnosis and management of intestinal malrotation can potentially prevent the devastating complications associated with midgut volvulus. Atypical presentation of intestinal malrotation in older children frequently leads to a significant...

Abdominal pain with a twist

Malrotation in children is due to either an incomplete or non-rotation of the foetal mid-gut during perinatal development. Presentation is usually in the first few weeks of life, often with life-threatening volvulus and ischaemia. However, it can be a rare cause of abdominal pain in older children and young adults. We present such a case, as a reminder to emergency physicians that malrotation should be considered in the differential diagnosis of recurrent or chronic abdominal pain not only in children but also in adolescents.

Management of gastroesfophageal reflux associated with malrotation in children

Aim Children being investigated for gastroesophageal reflux (GOR) have a high incidence of malrotation. Current literature suggests these patients should be managed with a combined antireflux and Ladd's procedure. We review our experience, the largest series to date, of performing an elective Ladd's procedure as the first-line intervention. Method Retrospective case note review of 20 children with significant symptoms of GOR and an incidental finding of malrotation. Children presenting immediately with bilious vomiting were excluded. All patients underwent a Ladd's procedure as their sole primary operative intervention. Results Median age at operation was 7 months (21 days-12 years). Fifteen patients (75%) had evidence of reflux on barium contrast study. All children were followed up for at least 6 months. Eighteen (90%) had resolution or significant improvement of their symptoms postsurgery. Only 3 have not managed to tolerate a full oral diet, all unrelated to GOR. None of our series required an antireflux procedure. Conclusion In children with debilitating vomiting necessitating surgical management, a contrast study is imperative in the work up. The high incidence of GOR and the significant improvement after correction of malrotation show the relationship between delayed gastric emptying and GOR. We suggest that when an abnormally placed duodenojejunal flexure is found, a Ladd's procedure alone is sufficient and may obviate the need for a more invasive antireflux procedure.

Outcomes of surgical treatment of malrotation in children

Abnormalities of rotation and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with volvulus which has catastrophic consequences when diagnosis is delayed or not even considered. This study evaluates the outcomes of surgical management of intestinal malrotation (IM) in children. The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2000 and September 2009, were reviewed. Patients' characteristics, management, complications, and survival were evaluated. Nine patients (eight boys and a girl) underwent surgery for malrotation at a median age of 15 days. Eight presented with acute symptoms and one with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in two of them. Volvulus was found at the time of surgery in seven patients, five of whom were neonates. One patient also had associated mesentery cyst. Seven patients were treated by Ladd's operation. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was one perioperative death from anastomostic leak. Median length of stay was 9 days. Postoperative bowel obstruction was seen in two patients (one died), resulting in an overall mortality of 22.2%. Bowel gangrene from volvulus contributes to mortality, and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for IM. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention. There is a need for high index of suspicion in babies with bilious vomiting especially when recurrent to prevent devastating complications when present.

Presentation and Outcome of Surgical Treatment of Malrotation in Children

Introduction : Malrotation is a common anomaly in the pediatric age group which includes a wide spectrum of anomalies of Rotation. Both acute and chronic presentations are common. Atypical malrotation not having all the features of classic mal Rotation is frequently found which a diagnostic dilemma and the management varies from centre to centre. Materials and Methods : The medical records of all patients with symptomatic malrotation, who underwent surgery between July 2001 to June 2011, were retrospectively reviewed. Patients’ presentation, management, operative findings and complications were evaluated. Results : 68 patients underwent surgery for malrotation at a median age of 2 years. Male to female ratio was 2:1. 28(41%) presented with acute symptoms and 40(59%) with chronic symptoms. 54(79%) patients had vomiting, 36 (%3%) presented with abdominal distension, 19(28%) had recurrent abdominal pain. Diagnostic laparoscopy was done in 7(10%) patients. Ladd’s band was found in 16(24%) patients and Volvulus was found at the time of surgery in 5(7%) patients. 5(7%) patients also had associated anomalies. Ladd’s procedure was done in 15(22%) patients and 23(34%) patients needed resection and anastomosis. Median length of hospital stay was 10 days. Postoperative bowel obstruction was seen in 4(6%) patients and 2(3%) patients had post operative intussusceptions. There was 2(3%) death due to septicaemia with volvulus and gangrenous gut. Conclusion : The clinical presentation and anatomy of malrotation occurs along a wide clinical and anatomic variations and a high index of suspicion is required to prevent a delay in diagnosis. JCMCTA 2011; 22(2): 17-21

Mésentère commun complet révélé par une appendicite perforée gauche: Common mesentery presenting with left-sided perforated appendicitis

Intestinal malrotation in children is a rare aberration, due to a halt in the rotation and attachment of the primitive gut, it can be asymptomatic if the rotation terminates at 90 degrees, which manifests itself in unusual forms of appendicitis as in our observation, or dangerous in cases of inadequate common mesentery and worsened by small intestine volvulus. This 12-year-old boy experienced abdominal discomfort in the hypogastrium and left iliac fossa 4 days before admission. The pain had been developing in a feverish setting, and the clinical examination had revealed abdominal sensitivity. A biological inflammatory syndrome was detected throughout the biological workup, the CT scan allowed the diagnosis of acute appendicitis on a complete common mesentery, and the patient underwent a laparotomy appendectomy. Even though children frequently experience acute appendicitis in its conventional form, it is nevertheless highly challenging to identify in its atypical forms when intestinal malrotation is involved. An abdominopelvic CT scan is used to make the diagnosis, and appendectomy, preferably with laparoscopy, is the recommended course of action.

Long-term complications following operative intervention for intestinal malrotation: a 10-year review

Intestinal malrotation associated with a volvulus requires immediate surgical intervention. The long-term sequelae of Ladd's procedure and its complications are not well defined. We designed this study to investigate the long-term complications following operative intervention for intestinal malrotation. Patients who have undergone a Ladd's procedure for malrotation from January 1999 till December 2008, from two tertiary centres, were identified using the Hospital Inpatient Enquiry system. Charts were analysed to obtain information about mode of presentation, method of diagnosis and postoperative outcomes. Patients were contacted for follow-up. One hundred and sixty-one patients were identified over the 10-year period with a postoperative follow-up time ranging from 2 months to 10 years. The median age at surgery was 9 days (1 day-12 years); 38 (23%) underwent elective Ladd's procedure for malrotation. Thirty-eight patients had intraoperative incidental findings of a malrotation during different procedures; 120 (74.5%) patients were performed as an emergency procedure. Fourteen patients (8.7%) developed complications following surgery. Nine patients developed adhesive small bowel obstruction, five required operative adhesiolysis having failed conservative treatment. There was one case of recurrent volvulus and three mortalities in our series. In our experience, looking at 161 patients with a mean follow-up of 5 years Ladd's procedure has a low postoperative morbidity and remains a vital treatment for malrotation in children.

Clinical Spectrum of Malrotation in Children

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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.

Gastro-oesophageal reflux and intestinal malrotation in children

In a series of 74 children undergoing Nissen fundoplication for persistent gastro-oesophageal reflux unresponsive to intensive medical treatment, there was an unexpectedly high incidence (54 per cent, n = 40) of intestinal malrotation. The series was not homogeneous, 25 of the children having reflux as a complication of a serious congenital abnormality (48 per cent incidence of intestinal malrotation), and 49 presenting with 'idiopathic' reflux (57 per cent incidence of intestinal malrotation). Intestinal malrotation is best detected pre-operatively by careful barium radiology, requiring clinicians to be aware of the association. In our experience, in children over the age of 3 months, both an antireflux operation and Ladd's procedure are often necessary to stop gastro-oesophageal reflux when an intestinal malrotation is present.

Should malrotation in children be treated differently according to age?

Purpose: The aim of this study was to better define the mode of presentation, rate of volvulus, and surgical findings in children younger than 2 versus older than 2 years of age with malrotation. Methods: The authors reviewed the charts of all patients with malrotation admitted to their hospital between January 1980 and December 1998, excluding patients having malrotation as a secondary finding. Results: An upper gastrointestinal series was done in 90 patients (6% falsely negative) and a barium enema in 20 patients (40% read as normal). Fifty-eight patients had 114 associated congenital anomalies. Volvulus was found at the time of surgery in 28 patients, 5 of whom were older than 2 years. Three presented with acute symptoms and 2 with chronic symptoms. Surgery was performed by laparotomy in 103 patients and by laparoscopy in 3. Mean length of stay was 13.6 days. Mean follow-up was 19 months. Death occurred in 4 patients; postoperative bowel obstruction was seen in 3 patients (only 1 required surgery). Conclusions: Children with malrotation who are older than 2 years old have a significant risk of volvulus that is difficult to predict radiologically. They require surgical attention even if asymptomatic. Laparoscopy allows evaluation of the base of the mesentery and completion of the Ladd's procedure. J Pediatr Surg 35:756-758. Copyright © 2000 by W.B. Saunders Company.

Laparoscopic treatment of intestinal malrotation in children.

Laparoscopic treatment of intestinal malrotation in children is difficult, and most of our pediatric surgeon colleagues active in the field of laparoscopic surgery tell us that more often than not they must convert to an open procedure. Initially, we experienced much difficulty too, but after modification we were able to master the technique, and now we feel confident. We here describe the actual technique we use. Our experience encompasses nine children treated during the past 18 months. Five of the children presented in the newborn period and four later. During laparoscopic surgery, it is of paramount importance to concentrate not on the loops of bowel, but on the duodenum. By starting to identify the duodenum, mobilizing it, and carrying on the mobilization of the small bowel down until the whole small bowel has been seen, the pathologic anatomy is easily unraveled. Moreover, an existing volvulus is automatically reduced and the bowel automatically put in a nonrotation position in the abdomen. All patients have done well, and no complications have been noted. Operative time has been reduced to about 1 hour. Laparoscopic treatment of intestinal malrotation in children is not so difficult provided certain rules, as described, are followed.

Radiographic patterns of intestinal malrotation in children.

Intestinal malrotation is a major diagnostic challenge in children. Sometimes the prognostic significance of the findings from upper gastrointestinal tract examinations is unclear. In a series of 69 surgically proved cases, the authors studied the prevalence and clinical consequences of various radiographic patterns of malrotation and correlated surgical findings with the radiographic location of the duodenum and cecum. Seven patterns of duodenal malrotation were observed. Almost all children in the series had abnormalities of rotation or fixation of both the duodenum and colon, resulting in narrowing of the mesenteric base with potential for midgut volvulus. Of 69 patients, only one (1.4%) had an anatomically normal duodenum, and four (5.8%) had a surgically confirmed normal cecum fixed in the right lower quadrant. In the absence of a corkscrew or Z-shaped duodenum, patterns that usually indicate volvulus or obstructing Ladd bands, colon position had greater prognostic implication, especially when the cecum was situated in the right upper quadrant or left upper quadrant. These latter patterns were associated with the highest prevalence of volvulus.