Volvulus In Patient Research Articles

Analysis of clinical diagnosis and treatment of intestinal volvulus

BackgroundThe aim of this study is to investigate the clinical characteristics and treatment experience of intestinal volvulus, and to analyze the incidence of adverse events and related risk factors of intestinal volvulus.MethodsThirty patients with intestinal volvulus admitted to the Digestive Emergency Department of Xijing Hospital from January 2015 to December 2020 were selected. The clinical manifestations, laboratory tests, treatment and prognosis were retrospectively analyzed.ResultsA total of 30 patients with volvulus were enrolled in this study, including 23 males (76.7%), with a median age of 52 years (33–66 years). The main clinical manifestations were abdominal pain in 30 cases (100%), nausea and vomiting in 20 cases (67.7%), cessation of exhaust and defecation in 24 cases (80%), and fever in 11 cases (36.7%). The positions of intestinal volvulus were jejunum in 11 cases (36.7%), ileum and ileocecal in 10 cases (33.3%), sigmoid colon in 9 cases (30%). All 30 patients received surgical treatment. Among the 30 patients underwent surgery, 11 patients developed intestinal necrosis. We found that the longer the disease duration (> 24 h), the higher the incidence of intestinal necrosis, and the higher the incidence of ascites, white blood cell count and neutrophil ratio in the intestinal necrosis group were significantly higher than those in the non-intestinal necrosis group (p < 0.05). After treatment, 1 patient died of septic shock after operation, and 2 patients with recurrent volvulus were followed up within 1 year. The overall cure rate was 90%, the mortality rate was 3.3%, and the recurrence rate was 6.6%.ConclusionLaboratory examination, abdominal CT and dual-source CT are very important for the diagnosis of volvulus in patients with abdominal pain as the main symptom. Increased white blood cell count, neutrophil ratio, ascites and long course of disease are important for predicting intestinal volvulus accompanied by intestinal necrosis. Early diagnosis and timely intervention can save lives and prevent serious complications.

Laparoscopic Sigmoidopexy for Acute Sigmoid Volvulus – A Case report with Review of Literature

Sigmoid volvulus is the most common type of colonic volvulus and occurs when a portion or whole of the sigmoid colon twists around its blood supply. In sigmoid volvulus, this occurs at the base of the mesentery. Sigmoid volvulus often recurs and it is controversial whether preventive surgery should be performed in recurrent cases, especially in elderly and high-risk cases. Herein, we report the case of an 83 year old man with Parkinson’s disease who presented with acute sigmoid volvulus and was successfully treated with laparoscopic sigmoidopexy i.e. fixation of the untwisted colon to the abdominal wall. Laparoscopic sigmoidopexy may be an acceptable treatment for acute sigmoid volvulus in patients unwilling to undergo definitive resection with colostomy.

S195 Is There a "Golden Window" for Endoscopic Reduction of Acute Sigmoid Volvulus: A Multicenter Retrospective Study

Introduction: Colonic volvulus accounts for around 2% of all bowel obstructions in the United States. the involvement of the sigmoid colon consists of the overwhelming majority of colonic volvulus cases, possibly 60.9–80%. [1]. Per the American Society of Gastrointestinal endoscopy guidelines (ASGE), Non-operative detorsion with flexible sigmoidoscopy is considered first-line therapy in the management of sigmoid volvulus in patients without signs of peritonitis, perforation, or with recurrent or unsuccessful nonoperative decompression [2][3][4]. Despite this recommendation, the ideal timing for endoscopic intervention remains unclear. Methods: We conducted a retrospective study in adult patients admitted for acute sigmoid volvulus in 4 academic centers from January/2010-January/2020. 47 Patients were identified using ICD-9 and ICD-10 codes. Inclusion criteria included adult patients who were initially managed with endoscopic detorsion. The time interval between diagnosis and endoscopic intervention was collected. Primary outcomes included the need for subsequent urgent surgical intervention within 30 days of the endoscopic intervention. Secondary outcomes were hospital length of stay and mortality. Results: A total of 47 patients met the inclusion criteria. 33 patients were males (70.2%). The mean age of the sample was 71.0 (±16.5) years. Successful non-surgical reduction was achieved in 43 patients (91.5%). Endoscopic intervention was aborted in 4 patients for concerns of bowel ischemia or nonviable mucosa. 31 (66%) patients required urgent surgical intervention within 30 days of the endoscopic reduction, with an average interval period of 7 (±8.5) days. Surgical interventions included Hartmann’s procedure, sigmoid colectomy with primary colorectal anastomosis, and total abdominal colectomy. Early endoscopic reduction resulted in fewer subsequent urgent and emergent surgical interventions (p-value = 0.013). Using the ROC curve, a cut-off point of 8.5 hours was determined to be predic table of favorable outcomes with a sensitivity and specificity of 74.2%, and 75%, respectively. (Figure) Early endoscopic intervention was associated with shorter hospitalization (p-value = 0.001). Conclusion: Endoscopic decompressive intervention within 8.5 hours of diagnosis of acute sigmoid volvulus decreased early volvulus recurrence, bowel ischemia and subsequent need for urgent surgical interventions. This in return decreased hospital length of stay and allowed for planned prophylactic surgical resection.Figure 1

Use of gastropexy for paraesophageal hernias—a narrative review

Background and Objective: Gastropexy involves surgical fixation of the stomach within the abdomen to prevent re-herniation or volvulus in patients presenting with giant paraesophageal hernias. Multiple different techniques have been used and key ones will be reviewed here. This review focuses on the utility of gastropexy as a potential operative strategy to manage specific subsets of patients presenting with paraesophageal hernia and provides some historical context around the development of this technique in their operative management. While it is important to understand that hiatal hernia repair with creation of a gastrofundoplication has emerged as the current recommended standard of treatment in these patients, the use of gastropexy, while traditionally reserved in the emergent setting for patients presenting with signs of acute gastric volvulus, may be evolving as an option for patients undergoing elective or semi-elective repair of large paraesophageal hernias.

Role of ultrasonography and computed tomography in stomach and bowel diseases

Background-In this study we compared ultrasound with CT in detecting causes of Common stomach and bowel pathologies such as appendicitis, diverticulitis, volvulus in patients presenting at the department with acute abdominal pain in the majority of cases. Methods- A cross-sectional study was conducted in our institute from September 2019 to August 2021 following approval from the Ethical committee of the hospital. All clinically suspected lesions involving stomach and bowel patients included patients who were clinically evaluated at OPD &amp; the emergency department by the surgeon. All those who fulfilled the inclusion criteria were explained the purpose of the study. After clinical assessment, all consenting patients underwent ultrasound and computed tomography (CT) within a few hours of presentation.&#x0D; Results- A total of 100 patients with stomach and bowel disorders were studied using ultrasound and multidetector CT scan. 25 patients were diagnosed with appendicular pathologies, 25 cases with primary neoplasms, 18 were abdominal Koch’s, 17 were Crohn’s disease, 6 were ulcerative colitis, 4 were volvulus, 3 were diverticulitis, 2 were intussusception.Acute appendicitis was the most frequent finding seen in 23 patients. Ultrasound was diagnostic in all except one case.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

Intrauterine midgut volvulus as a rare cause of intestinal obstruction: a case report

BackgroundIntrauterine midgut volvulus is a very rare, life-threatening condition, and prenatal diagnosis is difficult. In this article, we present a case of midgut volvulus followed by a pre-diagnosis of antenatal jejunal atresia.Case presentationA 1-day-old Turkish male baby, who was followed with a diagnosis of antenatal jejunal atresia, with a birth weight of 3600 g, delivered by cesarean section at 38 weeks of gestation from a 19-year-old mother in her fourth pregnancy, was taken to the newborn intensive care unit. The patient underwent surgery on the postnatal first day with a preliminary diagnosis of jejunal atresia. It was observed that the small intestine was rotated two full cycles from the mesenteric root. Bowel blood circulation was good. Volvulus was untwisted. There was malrotation. Ladd's procedure was performed. The baby was discharged on the seventh postoperative day with full oral feeding. The patient is still in the first postoperative year and follow-up has been uneventful.ConclusionIntrauterine midgut volvulus has been associated with high mortality in the literature. Differential diagnosis of midgut volvulus in patients with antenatal intestinal obstruction, close prenatal follow-up, appropriate delivery and timing of surgical intervention may significantly reduce morbidity and mortality.

Volvulus of the ileal pouch-anal anastomosis: a meta-narrative systematic review of frequency, diagnosis, and treatment outcomes.

BackgroundProctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA.MethodsA systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018.ResultsThe frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%).ConclusionPouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

The risk of midgut volvulus in patients with abdominal wall defects: A multi-institutional study

BackgroundThe management of malrotation in patients with congenital abdominal wall defects has varied among surgeons. We were interested in investigating the risk of midgut volvulus in patients with gastroschisis and omphalocele to help determine if these patients may benefit from undergoing a Ladd procedure. MethodsA retrospective chart review was performed for all patients managed at three institutions born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy. ResultsOf the 414 patients identified with abdominal wall defects, 299 patients (72%) had gastroschisis, and 115 patients (28%) had omphalocele. The mean gestational age at birth was 36.1±2.3weeks, and the mean birth weight was 2.57±0.7kg. There were a total of 8 (1.9%) cases of midgut volvulus: 3 (1.0%) patients with gastroschisis compared to 5 patients (4.4%) with omphalocele (p=0.04). ConclusionsPatients with omphalocele have a greater risk of developing midgut volvulus, and a Ladd procedure should be considered during definitive repair to mitigate these risks. Level of evidenceIII; retrospective comparative study

Screening and Treatment of Intestinal Rotational Abnormalities in Heterotaxy: A Systematic Review and Meta-Analysis

To assess the role of screening and prophylactic surgery for intestinal rotational abnormalities (IRAs) in asymptomatic patients with heterotaxy. PubMed, Embase, and Cinahl were searched electronically to determine the overall incidence of IRAs in heterotaxy; the detection rate of IRAs associated with screening; the incidence of midgut volvulus in patients without screening; and the incidence of morbidity and mortality after prophylactic and emergency Ladd procedures. Relevant data were computed with a meta-analysis of proportions. Between-study heterogeneity was assessed with the I(2) statistic. From 276 papers identified, 24 studies with a total of 1433 patients with heterotaxy were included for systematic review. No randomized study was identified. True incidence of IRA in heterotaxy could not be ascertained through meta-analysis. In patients who underwent screening, the incidence of IRA was 58%. Acute midgut volvulus occurred in 5.8% of those who did not undergo screening. Postoperative mortality after Ladd procedure mainly was associated with cardiac insufficiency, and overall it was significantly greater in the emergency group compared with the prophylactic group (18% vs 5.6%). The complication rate also was greater in case of emergency vs prophylactic abdominal surgery (27% vs 16%); adhesional small bowel obstruction was the most common complication overall (6%). The screen-detected incidences of IRA and acute midgut volvulus were significantly greater in heterotaxy than the normal population. Prophylactic Ladd procedure was associated with less morbidity and mortality compared with emergency surgery. A long-term prospective randomized trial is needed to define the indication for screening and prophylactic treatment of IRA in heterotaxy.

Heterotaxy and intestinal rotation anomalies: 20 years experience at a UK regional paediatric surgery centre.

The association of heterotaxy with intestinal rotation anomalies is well described. However debate exists with regard optimal management notably should 'asymptomatic' bowel rotation anomalies undergo operation? The present study therefore sought to determine: (1) the risk(s) of volvulus in patients diagnosed with heterotaxy and (2) define morbidity associated with operation for 'asymptomatic' anomalies in a fragile patient cohort with co-existent congenital heart disease. Medical case record reviews of ALL heterotaxy patients born during January 1993-December 2013 and attending a UK paediatric centre were analyzed. Of a total of 92 patients, 16 (17.4%) cases underwent foregut imaging studies. Three examinations were performed in 'symptomatic' patients. Twelve studies reported 'abnormal anatomy' with only five patients undergoing surgical correction. No complication(s) were recorded after Ladd's operation to correct defects. A single fatality occurred within 30 days postoperatively from cardiac failure. In 87 patients in whom Ladd's operation was not undertaken, no single patient developed intestinal volvulus (median length of follow-up 27.2 months, total 446.1 person years). This study strongly supports a 'watchful waiting' policy for heterotaxy patients. Many children who ultimately die from heart disease may avoid unnecessary abdominal surgery.

Epigastric pain: Incarceration or rotation?

Introduction: Acute intrathoracic gastric volvulus occurs when the stomach has a twist mesenteroaxial/organoaxial or chest cavity resulting in a dilatation or rupture of the diaphragmatic hiatus or diaphragmatic hernia. the purpose of this work is to show a interesting case of gastric volvulus in a patient with several comorbidities. case report: A 77-year-old female with past history of hiatal hernia and mental disease associated with diabetes and atrial fibrillation. Patient went to the emergency department due to vomiting associated with blood. Analytical parameters (Wbc, HGb, Pcr, metabolic panel and liver function), showed no significant alterations. thoracic X-ray revealed an enlarged mediastinum due to herniation of the stomach. A computed tomography (ct) scan confirmed intrathoracic localization of the gastric antrum with twist. Patient's symptoms were relieved by nasogastric intubation and analgesia. After six months, the patient is still asymptomatic. conclusion: In general, the treatment of an acute gastric volvulus requires an emergent surgical repair. In patients who are not surgical candidates (with comorbidities or an inability to tolerate anesthesia), endoscopic reduction should be attempted. chronic gastric volvulus may be treated non-emergently, and surgical treatment is increasingly being performed using a laparoscopic approach. In this case, it is a chronic form that was solved with the placement of the nasogastric tube. A nasogastric decompression is an option in the chronic form of hiatal hernia associated to gastric volvulus in patients with serious comorbidities.

The risk of volvulus in abdominal wall defects

BackgroundCongenital abdominal wall defects are associated with abnormal intestinal rotation and fixation. A Ladd's procedure is not routinely performed in these patients; it is believed intestinal fixation is provided by adhesions that develop post-repair of the defects. However, patients with omphalocele may not have adequately protective postoperative adhesions because of difference in the inflammatory state of the bowel wall and in repair strategy. The aim of this study is to describe the occurrence of midgut volvulus in patients with gastroschisis or omphalocele. MethodsA retrospective chart review was performed for all patients managed in a single institution born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy. ResultsOf the 206 patients identified with abdominal wall defects, 142 patients (69%) had gastroschisis and 64 patients (31%) had omphalocele. Patients' follow up ranged from 4years to 13years. The median gestational age was 36weeks (26–41weeks) and the median birth weight was 2.42kg (0.8–4.87kg). None of the patients with gastroschisis developed midgut volvulus, however two patients (3%) with omphalocele developed midgut volvulus. ConclusionsNo patients with gastroschisis developed midgut volvulus. Therefore, the current practice of not routinely performing a Ladd's procedure is a safe approach during surgical repair of gastroschisis. The two cases of volvulus in patients with omphalocele may be related to less bowel fixation. It is necessary to examine current practice in regards to the need for assessing the risk of volvulus during omphalocele closure and counseling of these patients. This assessment may be achieved via routine examination of the width of the small bowel mesenteric base, whenever feasible; however, the sample size is relatively small to draw any definitive conclusions.

Percutaneous endoscopic colostomy (PEC): an effective alternative in high risk patients with recurrent sigmoid volvulus.

Treatment of recurrent sigmoid volvulus is a major challenge in frail and elderly patients with multiple co-morbidities. Early management involves endoscopic decompression with high success rate, however, its recurrence make it a real challenge as most of these patients are not suitable for major colonic resection. The aim of this study was to assess the role of percutaneous endoscopic colostomy (PEC) in the treatment of recurrent sigmoid volvulus in these patients. Twelve PEC procedures were performed in 8 patients under our care. This prevented major colonic resection in 7 patients. One patient underwent sigmoid resection and died with postoperative complications. Two patients experienced minor complications. Three patients required repeat procedures for permanent PEC tube placement. Six patients managed permanently with PEC procedure. PEC is an effective treatment for recurrent sigmoid volvulus in high-risk elderly patients.

Laparoscopic Treatment of Acute Gastric Volvulus

IntroductionGastric volvulus is an uncommon clinical condition and is associated with type II–III hiatal hernias. Its acute presentation constitutes a surgical emergency. Despite its low frequency, results of laparoscopic treatment have already been published. Material and methodsA retrospective study was performed on all cases diagnosed with gastric volvulus undergoing laparoscopic surgery between 1998 and 2010. The surgical technique, the post-operative outcome, and the clinical follow-up are described. ResultsA total of 10 cases were identified, one was a primary gastric volvulus, and the remainder were secondary. A laparoscopic anterior gastropexy as the sole procedure was performed on 7 patients. A Nissen fundoplication with mesh reinforcement of the crural closure was performed on the 3 remaining cases. Postoperative outcome was uneventful in 9 patients, with an early start of the diet, and hospital discharge between 48 and 72h. After a mean follow-up period of 18 months, radiological hernia recurrence occurred in one case but recurrence of the volvulus was not observed. ConclusionLaparoscopic anterior gastropexy is, in our experience, an effective and safe procedure with a low morbidity, for the treatment of acute gastric volvulus in patients with high surgical risk.

Tratamiento del vólvulo gástrico agudo mediante abordaje laparoscópico

IntroductionGastric volvulus is an uncommon clinical condition and is associated with type ii-iii hiatal hernias. Its acute presentation constitutes a surgical emergency. Despite its low frequency, results of laparoscopic treatment have already been published. Material and methodsA retrospective study was performed on all cases diagnosed with gastric volvulus undergoing laparoscopic surgery between 1998 and 2010. The surgical technique, the post-operative outcome, and the clinical follow-up are described. ResultsA total of 10 cases were identified, one was a primary gastric volvulus, and the remainder were secondary. A laparoscopic anterior gastropexy as the sole procedure was performed on 7 patients. A Nissen fundoplication with mesh reinforcement of the crural closure was performed on the 3 remaining cases. Postoperative outcome was uneventful in 9 patients, with an early start of the diet, and hospital discharge between 48-72h. After a mean follow-up period of 18 months, radiological hernia recurrence occurred in one case but recurrence of the volvulus was not observed. ConclusionLaparoscopic anterior gastropexy is, in our experience, an effective and safe procedure with a low morbidity, for the treatment of acute gastric volvulus in patients with high surgical risk.

Radiological features of acute gastric volvulus in adult patients

Objective To evaluate the radiological features of acute gastric volvulus in adults and correlate these features with operative findings. Materials and Methods The clinical, radiological and operative findings of five adult patients (four males and one female with mean age of 50.4 years) who presented or referred to King Abdullah University hospital over 4 year’s period with symptoms of acute gastric volvulus were reviewed retrospectively. All patients underwent upper gastrointestinal barium study and two of them had computed tomographic (CT) scans preoperatively. The radiological features demonstrated on upper gastrointestinal barium exams and CT scans were analyzed and compared with operative findings. Results Radiological and operative findings revealed organo-axial gastric volvulus in all patients in our study. All of them had associated diaphragmatic defect or hiatal hernia. The upper gastrointestinal barium studies demonstrated the classic radiological features of organo-axial volvulus. CT done on two of our patients confirmed the diagnosis. Conclusion Upper gastrointestinal barium study is an accurate way to diagnose and characterize acute gastric volvulus in adult patients. CT scan can also be used to diagnose this clinical entity.

Incisionless Hartmann’s procedure: an innovative minimal access technique for surgical treatment of sigmoid volvulus in debilitated patients with faecal incontinence

Sigmoid volvulus requires decompression and subsequent surgical correction, and is often seen in debilitated patients. In an effort to decrease the physiological burden of surgery in these high-risk patients, we report an innovative minimal access technique for the definitive treatment of decompressed sigmoid volvulus in patients with concomitant faecal incontinence. A retrospective chart review of a series of two consecutive patients who had undergone a minimal access Hartmann's procedure (HP) between November 2005 and October 2006 was performed. A single skin incision of < or = 4 cm at the proposed colostomy site was used to identify, exteriorize, divide, and resect the redundant mesosigmoid and sigmoid colon. The same incision was used to mature the end-colostomy. No other incisions were created, and no laparoscopy or laparoscopic instruments were used. Perioperative clinical parameters and outcomes are reported. Patient 1 was a 94-year-old male, American Society of Anesthesiologists (ASA) class 4, who underwent a HP via a 4-cm skin incision under general anaesthesia in 150 min with a length of inpatient stay of 5 days. Patient 2 was an 83-year-old female, ASA class 3, who underwent a HP via a 3-cm skin incision under conscious sedation in 83 min, with a length of inpatient stay of 4 days. Estimated blood loss was <50 cm(3) for both patients, both patients had bowel function and were tolerating oral feeds upon discharge, and there was no perioperative morbidity or mortality in either patient at 30 days. Incisionless HP appears feasible in treating sigmoid volvulus and faecal incontinence in debilitated patients.

Non-toxic megacolon due to transverse and sigmoid colon volvulus in a patient with ulcerative colitis

Intestinal volvulus in patients with inflammatory bowel disease is rare.A 83-year-old woman diagnosed with ulcerative colitis five years ago was referred to our hospital due to abdominal distension. The patient had been diagnosed with pancolitis and dolichocolon and was started on mesalazine 1.5 g/day treatment resulting in long-term remission. Physical examination showed abdominal distention with no rebound; however on auscultation abdominal sounds were absent. Patient had no signs of toxicity. Temperature was 38.2 °C, heart rate was 82 bpm and respirations were 16/min. Laboratory investigation showed elevated white blood cell count (20,000/mm3) with hemoglobin at 13.2 g/dl and C-reactive protein at 310 mg/dl. Radiology was suggestive of megacolon and volvulus.Patient underwent endoscopy, which revealed normal rectal mucosa; there were however present areas of bowel gangrene. Urgent laparotomy was performed which revealed double transverse and sigmoid colon volvulus. A left hemicolectomy and transversectomy were performed.A case of a patient with ulcerative colitis is being presented here, exhibiting a non-toxic megacolon, resulting from a double transverse and sigmoid volvulus probably stemming from congenital dolichocolon. This case is stressing the importance of prompt differential diagnosis in such cases of megacolon as any symptom misinterpretation may result in unfavorable outcomes.

Outcomes after a Ladd procedure for intestinal malrotation with heterotaxia

Purpose Intestinal rotation abnormalities and complex congenital heart disease associated with heterotaxia coexist. Despite the risk for midgut volvulus, performing a Ladd procedure for asymptomatic malrotation with heterotaxia remains to be controversial because the presumed risk for postoperative complications is thought to exceed the benefits of the operation. The purpose of this study was to review the incidence of complications after a Ladd procedure in asymptomatic patients with heterotaxia to guide recommendations for this patient population. Methods The medical records of all patients with heterotaxia who underwent a Ladd procedure for asymptomatic malrotation between 1984 and 2004 were reviewed. Type of cardiac disease, postoperative complications, and survival were recorded. Results Twenty-two patients (9 boys and 13 girls) with heterotaxia underwent an elective Ladd procedure after their medical stabilization or surgical correction or palliation of their cardiac anomaly. Of these patients, 19 were younger than 1 month at the time of the operation. The remaining 3 patients underwent the operation when they were between 2 and 5 months old. Three of the 22 patients (14%) developed postoperative intestinal obstruction: lysis of adhesions was performed in 1 patient; another patient required a staged bowel resection for a closed loop obstruction; and yet another patient had recurrent midgut volvulus 4 years after an incomplete initial Ladd procedure. All patients survived the initial and secondary procedures. Four deaths, all more than 1 month after the surgery, occurred as sequelae of the underlying cardiac anomaly. Length of follow-up ranged from 1 to 17 years. Conclusions We report on a 14% risk of postoperative bowel obstruction after an elective Ladd procedure, as compared with a small but significant incidence of midgut volvulus in patients with malrotation in the setting of complex congenital heart disease. Our results support the conclusion that an elective Ladd procedure at a time of relative cardiac stability for selected patients with heterotaxia has an acceptably low morbidity and should be considered to prevent midgut volvulus.