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Collins GL, Hargis-Villanueva AE, Jayaraman MS, Lai K, Weidler EM, Griffiths PS, Rhee EK, Jorgensen S, Youssfi M, van Leeuwen K. A Prospective Management Strategy for Heterotaxy Syndrome with Intestinal Rotation Abnormalities: Imaging Does Not Predict Need for Surgery. J Pediatr Surg 2023; 58:1838-1842. [PMID: 36740478 DOI: 10.1016/j.jpedsurg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023]
Abstract
PURPOSE Heterotaxy syndrome (HS) affects right-left anatomical development in 3% of children with congenital heart disease. Commonly, these patients have intestinal rotation abnormalities (IRA) that differ from typical malrotation. In this prospective study, we examine the development of a management pathway, imaging findings, and clinical course of patients with HS and IRA. METHODS After literature review, a multispecialty focus group designed a pathway for HS. Participants from a single institution were prospectively enrolled from 2016 to 2019. They underwent an abdominal ultrasound and UGI, however timing was variable based on symptoms. Symptomatic IRA was defined as feeding intolerance, bilious or non-bilious vomiting, bloating, severe reflux, and intermittent pain or abdominal distention. Screening for symptoms occurred every three months for the first two years and then annually. RESULTS 18 participants were followed for a median of 5.0 years. Three clinical categories were identified: 1) asymptomatic, not requiring intestinal surgery, 72.2%, 2) symptomatic with feeding intolerance or failure to thrive requiring gastrostomy placement and diagnostic laparoscopy with Ladd procedure, 16.7%, and 3) symptomatic requiring urgent exploration for suspicion of volvulus, 11.1%. Need for surgery did not necessarily correlate with US and/or UGI findings. CONCLUSIONS In children with HS and IRA, postnatal imaging did not inform the need for intestinal surgery. Although rare, volvulus or other forms of proximal obstruction can be anticipated, and symptomatic patients should be offered surgical intervention. A multidisciplinary care pathway for patients with HS and IRA can coordinate care and help counsel families on the likelihood of needing intestinal surgery for IRA. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Prospective Cohort Study.
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Affiliation(s)
- Grant L Collins
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Angela E Hargis-Villanueva
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Meghna S Jayaraman
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Krista Lai
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Pamela S Griffiths
- Division of Neonatology, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Edward K Rhee
- Division of Cardiology, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Scott Jorgensen
- Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Mostafa Youssfi
- Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd., Phoenix, AZ, 85016, USA.
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Asymptomatic Intestinal Malrotation Progressing to Midgut Volvulus in a Decompensated Alcoholic Cirrhotic Adult: A Rare Scenario Requiring Special Considerations. Case Rep Surg 2020; 2020:4196012. [PMID: 32612864 PMCID: PMC7317621 DOI: 10.1155/2020/4196012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/17/2022] Open
Abstract
Intestinal malrotation usually presents in the pediatric population with midgut volvulus requiring emergency Ladd's procedure. Rarely, it remains asymptomatic and is discovered incidentally only during adulthood when it seldom causes intestinal complications. The scenario of a cirrhotic adult being diagnosed with asymptomatic intestinal malrotation with subsequent intestinal complications is thus extremely rare and to our knowledge has not been previously reported. We describe a 56-year-old man with decompensated alcoholic cirrhosis (Child-Pugh class C, MELD score 22) who was initially observed after an incidental diagnosis of intestinal malrotation on computed tomography. Observation continued as his liver disease improved with alcohol cessation (Child-Pugh class A, MELD score 8). He later presented with a closed loop bowel obstruction secondary to midgut volvulus at the time of alcohol relapse and liver redecompensation (Child-Pugh class C, MELD score 22-29). He underwent emergency Ladd's procedure during which his midjejunum was volvulized into an internal hernia space created by a thick Ladd's band containing large varices. The postoperative course was complicated by ileus and loculated bacterial peritonitis. Based on our experience, we discuss special considerations with regard to the surgical technique and timing of Ladd's procedure when encountering intestinal malrotation in a cirrhotic adult with portal hypertension.
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Sergi C, Hager T, Hager J. Congenital Segmental Intestinal Dilatation: A 25-Year Review with Long-Term Follow-up at the Medical University of Innsbruck, Austria. AJP Rep 2019; 9:e218-e225. [PMID: 31304051 PMCID: PMC6624109 DOI: 10.1055/s-0039-1693164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/26/2019] [Indexed: 12/24/2022] Open
Abstract
Background and Aim Congenital segmental intestinal dilatation (CSID) is a neonatal condition with unclear etiology and pathogenesis. Typically, the newborn with CSID presents with a limited (circumscribed) bowel dilatation, an abrupt transition between normal and dilated segments, neither intrinsic nor extrinsic perilesional obstruction, and no aganglionosis or neuronal intestinal dysplasia. We aimed to review this disease and the long-term follow-up at the Children's Hospital of the Medical University of Innsbruck, Tyrol, Austria. Study Design Retrospective 25-year review of medical charts, electronic files, and histopathology of neonates with CSID. Results We identified four infants (three girls and one boy) with CSID. The affected areas included duodenum, ileum, ascending colon, and sigmoid colon. Noteworthy, all patients presented with a cardiovascular defect, of which two required multiple cardiac surgical interventions. Three out of the four patients recovered completely. To date, the three infants are alive. Conclusion This is the first report of patients with CSID and cardiovascular defects. The clinical and surgical intervention for CSID also requires a thorough cardiologic evaluation in these patients. CSID remains an enigmatic entity pointing to the need for joint forces in identifying common loci for genetic investigations.
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Affiliation(s)
- Consolato Sergi
- Department of Orthopedics, Tianyou Hospital, Wuhan University of Science and Technology, Wuhan, Hubei, P.R. China.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas Hager
- Institute of Pathology, University Hospital of Essen, University Duisburg-Essen, Essen, Germany.,Institute of Pathology, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Hager
- Department of Pediatric Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Ryerson LM, Pharis S, Pockett C, Soni R, Fruitman D, Guleserian KJ, Nater M, Raynor SC, Mackie AS, Dicken B. Heterotaxy Syndrome and Intestinal Rotation Abnormalities. Pediatrics 2018; 142:peds.2017-4267. [PMID: 30049892 DOI: 10.1542/peds.2017-4267] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Infants with heterotaxy syndrome (HS) have abnormal lateralization of organs along the right-left body axis. Intestinal rotation abnormalities (IRAs) are a potential source of morbidity and mortality. For this study, our objective was to prospectively observe a cohort of infants with HS and determine the incidence and natural history of IRA. METHODS Infants ≤6 months of age with HS were enrolled in this prospective observational study. Exclusion criteria were other congenital abnormalities that necessitated abdominal surgery. HS was defined as any arrangement of organs that was not situs solitus or situs inversus along with associated congenital heart disease. The investigation for IRA was at the discretion of each participating center. RESULTS Infants were recruited from January 2012 to December 2016. Thirty-eight infants from 7 institutions were included; 22 infants had right isomerism and 16 infants had left isomerism. Twenty-nine infants (76%) were evaluated for IRAs; 21 of 29 evaluations (72%) were abnormal. Eight infants were investigated because of symptoms, and 21 infants were evaluated routinely. The median age at symptom presentation was 46 days (range: 5-171 days). Seven infants had a Ladd procedure; 4 were prophylactic, with 3 as part of a combined procedure, and 3 were emergent. No child suffered acute midgut volvulus over a median follow-up of 1.6 years (range: 0.06-4.93 years). CONCLUSIONS IRAs are common in infants with HS. Infants with symptoms presented by 6 months of age. There was no failure of expectant management resulting in midgut volvulus during a median follow-up of 1.6 years.
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Affiliation(s)
- Lindsay M Ryerson
- Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada;
| | - Scott Pharis
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Charissa Pockett
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Reeni Soni
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deborah Fruitman
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Melissa Nater
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Stephen C Raynor
- Division of Pediatric Surgery, Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, Nebraska; and
| | | | - Bryan Dicken
- Surgery, University of Alberta, Edmonton, Alberta, Canada
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Garg A, Sudhanthar S, Okeafor C. Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev 2017; 38:572. [PMID: 29196516 DOI: 10.1542/pir.2016-0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Anjali Garg
- College of Human Medicine, Michigan State University, East Lansing, MI
| | | | - Chioma Okeafor
- College of Human Medicine, Michigan State University, East Lansing, MI
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Putnam LR, Anderson KT, Tsao K, Kao LS, Lugo JA, Lally KP, Kawaguchi AL. The impact of cardiac risk factors on short-term outcomes for children undergoing a Ladd procedure. J Pediatr Surg 2017; 52:390-394. [PMID: 27894758 DOI: 10.1016/j.jpedsurg.2016.09.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 09/29/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure. METHODS The 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality. RESULTS 878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events. CONCLUSIONS Although overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children.
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Affiliation(s)
- Luke R Putnam
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Kathryn T Anderson
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of General Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.252, Houston, TX 77030, USA
| | - Jane A Lugo
- Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Kevin P Lally
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Akemi L Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA.
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7
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Intestinal malrotation in patients with situs anomaly: Implication of the relative positions of the superior mesenteric artery and vein. Eur J Radiol 2016; 85:1695-1700. [PMID: 27666604 DOI: 10.1016/j.ejrad.2016.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the usefulness of the relative position of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in diagnosing intestinal malrotation in situs anomaly. MATERIALS AND METHODS From January 2004 to April 2015, 33 patients with situs anomalies were enrolled in this study who underwent abdominal USG, CT or MRI as well as upper gastrointestinal series (UGIS) or surgery: situs inversus (n=16), left isomerism (n=10), and right isomerism (n=7); age 21.2±23.2years (mean±standard deviation), range 0-72 years. The intestinal malrotation was confirmed with UGIS and/or operation in 16 patients. Relative positions of the SMV to the SMA were classified into four groups by reviewing abdominal USG, CT, or MRI: right sided, left sided, ventral sided, and dorsal sided. The incidence of malrotation was analyzed for each group. RESULTS In 16 patients with situs inversus, there was reversed SMA-SMV relationship: left sided (n=11) or ventral sided (n=5). One situs inversus patient with ventral sided SMV had intestinal malrotation (6.25%). 17 patients with situs ambiguus showed various SMA-SMV relationships (ventral sided, n=7; left sided, n=5; right sided, n=4; dorsal sided, n=1). Among them, 15 patients (88.2%) had intestinal malrotation. Two patients with normal rotation had either right sided or dorsal sided SMV. CONCLUSION Situs ambiguus was commonly associated with intestinal malrotation with a variable SMA-SMV relationship. Reversal of the mesenteric vascular relationship was observed in situs inversus with normal rotation, not excluding the possibility of intestinal malrotation.
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Graziano K, Islam S, Dasgupta R, Lopez ME, Austin M, Chen LE, Goldin A, Downard CD, Renaud E, Abdullah F. Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg 2015. [PMID: 26205079 DOI: 10.1016/j.jpedsurg.2015.06.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. METHODS Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. RESULTS There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. CONCLUSIONS There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
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Affiliation(s)
- Kathleen Graziano
- Division of Pediatric General Surgery, Phoenix Children's Hospital, Phoenix, AZ.
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary Austin
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center; Department of Pediatric Surgery, University of Texas Medical School, Houston, TX
| | - Li Ern Chen
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, WA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD; Department of Surgery, University of Louisville, Louisville, KY
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Department of Surgery, Albany Medical Center, Albany, NY
| | - Fizan Abdullah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Larsen PO, Ellebæk MB, Pless T, Qvist N. Acute pancreatitis secondary to duodeno-duodenal intussusception caused by a duodenal membrane, in a patient with intestinal malrotation. Int J Surg Case Rep 2015; 13:58-60. [PMID: 26117447 PMCID: PMC4529645 DOI: 10.1016/j.ijscr.2015.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/28/2015] [Accepted: 06/07/2015] [Indexed: 12/12/2022] Open
Abstract
Intussusception is not always seen on ultrasonography but can revealed by a CT-scan. Any child, and especially those with previous congenital disorders, must undergo upper GI- endoscopy at the presence of intermittent upper gastrointestinal symptoms as vomiting, abdominal pain and gastro-oesophageal reflux, to exclude upper GI anomaly.
Duodeno-duodenal intussusception is often caused by an intraluminal tumour. The condition is rare owing to the retroperitoneal fixation of the duodenum, which is sometime absent in cases of intestinal malrotation. We describe the case of a 19-year old man admitted to hospital with abdominal pain and vomiting. A CT scan revealed a duodeno-duodenal intussusception including the head of the pancreas, which was confirmed by laparotomy. The cause was found to be a duodenal membrane with a pinhole passage combined with non-rotation of the duodenum.
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Affiliation(s)
| | | | - Torsten Pless
- Department of Gastrointestinal Surgery, Odense University Hospital, Denmark
| | - Niels Qvist
- Department of Gastrointestinal Surgery, Odense University Hospital, Denmark
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Pockett CR, Dicken BJ, Rebeyka IM, Ross DB, Ryerson LM. Heterotaxy syndrome and intestinal rotation abnormalities: a survey of institutional practice. J Pediatr Surg 2013; 48:2078-83. [PMID: 24094961 DOI: 10.1016/j.jpedsurg.2013.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/04/2013] [Accepted: 03/01/2013] [Indexed: 12/21/2022]
Abstract
PURPOSE Abnormalities of intestinal rotation (IRA) are commonly associated with heterotaxy syndrome (HS). There is controversy whether asymptomatic infants with HS require screening for IRA and if present, whether a prophylactic Ladd procedure is indicated. The objective of this study is to determine institutional practice across North America in the management of asymptomatic infants with HS and IRA. METHODS We performed an international, multi-institutional web based survey to examine current practice and opinions in the management of IRA in HS patients. RESULTS Overall response rate was 30%. Of physicians surveyed, 84% believe that HS patients should be screened for IRA in the neonatal period. 61% of general surgeons, 50% of cardiovascular surgeons and 45% of cardiologists feel that all patients with HS and an asymptomatic IRA should have a prophylactic Ladd procedure. 55% of physicians stated they would be comfortable with conservative management for patients with HS and asymptomatic IRA. CONCLUSIONS The risk of midgut volvulus, morbidity and mortality from elective procedures and cardiovascular prognosis must be considered prior to an elective Ladd procedure on asymptomatic HS patients. There are practice variance among sub-specialists caring for these patients, a lack of expert consensus, and a paucity of evidence-based data for IRA in this population.
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Heterotaxy syndrome: is a prophylactic Ladd procedure necessary in asymptomatic patients? Pediatr Cardiol 2013; 34:59-63. [PMID: 22644418 DOI: 10.1007/s00246-012-0385-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
Abstract
Heterotaxy syndrome (HS) is a complex disorder involving thoracic and abdominal asymmetries. Congenital heart disease is often accompanied by an intestinal rotation abnormality (IRA) that may predispose to bowel ischemia and infarction. There is controversy in the literature whether asymptomatic infants with HS must be screened for IRA and, if present, whether a prophylactic Ladd procedure should be performed. We performed a retrospective chart review of all patients who underwent a Ladd procedure from January 2007 to December 2010 at Stollery Children's Hospital, Edmonton, Canada. Twenty-nine patients underwent a Ladd procedure, 22 without HS but with symptomatic malrotation and 7 with HS and asymptomatic malrotation. Asymptomatic HS patients had a complication rate of 57 % after a prophylactic Ladd procedure compared with a complication rate of 9 % in the symptomatic non-HS population. The management of asymptomatic IRA in patients with HS remains controversial. We suggest that HS patients be screened for IRA and that asymptomatic patients be managed conservatively.
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