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Yang X, Wang W, Wang K, Zhao J, Sun L, Jiang S, Wang Y, Feng W, Ding G, Fu T, Li A, Geng L. Identification and treatment of intestinal malrotation with midgut volvulus in childhood: a multicenter retrospective study. Front Pediatr 2024; 12:1390856. [PMID: 38803636 PMCID: PMC11128588 DOI: 10.3389/fped.2024.1390856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
Background 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. Methods Clinical data, imaging, operative findings, and early postoperative outcomes of 75 children with malrotation were retrospectively analyzed. Results 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). Conclusions 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.
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Affiliation(s)
- Xiaofeng Yang
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Wei Wang
- Department of Surgery, Maternity and Child Health Care of Zaozhuang, Zaozhuang, Shandong, China
| | - Kun Wang
- Department of Pediatric Surgery, The People’s Hospital of Rizhao, Rizhao, Shandong, China
| | - Jingquan Zhao
- Department of Surgery, Zibo Maternal and Child Health Hospital, Zibo, Shandong, China
| | - Liandong Sun
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Shuai Jiang
- Department of Pediatric Surgery, Liaocheng People’s Hospital, Liancheng, Shandong, China
| | - Yewen Wang
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Wenyu Feng
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Guojian Ding
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Tingliang Fu
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Aiwu Li
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Lei Geng
- Department of Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
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Venkatakrishna SSB, Elsingergy M, Calle-Toro JS, Dennis R, Otero HJ, Andronikou S. Quality and Diagnosis on the Lateral View of Pediatric Upper Gastro-Intestinal Series. CHILDREN (BASEL, SWITZERLAND) 2024; 11:151. [PMID: 38397262 PMCID: PMC10887497 DOI: 10.3390/children11020151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. OBJECTIVE We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. MATERIALS AND METHODS This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. RESULTS A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. CONCLUSIONS A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient.
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Affiliation(s)
| | - Mohamed Elsingergy
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Juan S. Calle-Toro
- Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Rebecca Dennis
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hansel J. Otero
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Savvas Andronikou
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Calle-Toro JS, Elsingergy MM, Dennis R, Grassi D, Kidd M, Otero H, Andronikou S. Frequency of duodenal anatomical variants in neonatal and pediatric upper gastrointestinal tract series (UGI) and the influence of exam quality on diagnostic reporting of these. Clin Imaging 2022; 87:28-33. [DOI: 10.1016/j.clinimag.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
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Pancreaticobiliary maljunction and pancreas divisum accompanied with intestinal malrotation: a case report. BMC Pediatr 2022; 22:110. [PMID: 35227232 PMCID: PMC8883662 DOI: 10.1186/s12887-022-03171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Pancreaticobiliary maljunction is a congenital anatomical abnorma l junction of the pancreatic duct and bile duct into a common channel outside the duodenal wall. Pancreas divisum is also a congenital anatomical abnormality characterized by unfused pancreatic ducts. Intestinal malrotation is caused by the failure of bowel rotation and fixation. We reported an optimal surgical intervention for the rare case of pancreaticobiliary maljunction and pancreas divisum accompanied intestinal malrotation. Case presentation A 2-year-old female presented with fever and jaundice. Abdominal ultrasound showed dilated common bile duct and intrahepatic bile ducts; MRCP showed pancreaticobiliary maljunction, pancreas divisum, and dilated biliary system; Abdominal contrast-enhanced CT showed a reversed relationship between the superior mesenteric artery and the superior mesenteric vein. An operation of laparoscopic resection of the extrahepatic bile duct, Roux-en-Y hepaticojejunostomy, and Ladd’s procedure was performed after the inflammation of the biliary system was treated. The post-operative follow-up period was uneventful. Conclusions The management of pancreas divisum can be conservative. We present an optimal pattern of Roux-en-Y hepaticojejunostomy to deal with pancreaticobiliary maljunction associated with intestinal malrotation.
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Bollard KA, Valsenti G, Healey D, Murdoch J. The adequacy of fluoroscopic upper gastrointestinal studies for suspected intestinal volvulus in a tertiary care centre vs. secondary centres: A regional multicentre study. J Med Imaging Radiat Oncol 2021; 65:293-300. [PMID: 33634557 DOI: 10.1111/1754-9485.13156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/11/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Early diagnosis and treatment of intestinal volvulus are important to reduce morbidity. A fluoroscopic upper GI study is the gold standard for diagnosis and may be performed in a secondary or tertiary care centre prior to surgery. It is important the reporting radiologist is confident in the findings. We aim to assess whether there is any difference in confidence and study quality between paediatric and general radiologists who work in secondary or tertiary care centres. METHODS Retrospective review of initial radiology reports and blinded review of the study images by paediatric radiologists. RESULTS A total of 277 children underwent a fluoroscopic study for intestinal volvulus over a four-year period. The majority were performed at a tertiary care centre, by paediatric radiologists. The confidence of initial reporting was higher in paediatric than general radiologists despite whether they worked in a secondary or tertiary care centre (P-value < 0.001). On retrospective review, studies performed by paediatric radiologists were rated as having a higher confidence in identifying the location of the duodenojejunal flexure. General radiologists tended to have a slightly higher rate of repeat studies but still low at 2.2%. Despite this, there was no significant difference in the diagnosis rates and secondary centre general radiologists excluded malrotation in 62% of studies likely reducing transfer rates. CONCLUSION Confidence in initial reporting and on review of the duodenojejunal flexure location in suspected intestinal volvulus is higher in paediatric radiologists compared with general radiologists, although diagnosis rates are no different.
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Affiliation(s)
- Kate Amelia Bollard
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Gianluca Valsenti
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - David Healey
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Jean Murdoch
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
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Shalom NE, Gong GX, Auster M. Fluoroscopy: An essential diagnostic modality in the age of high-resolution cross-sectional imaging. World J Radiol 2020; 12:213-230. [PMID: 33240462 PMCID: PMC7653184 DOI: 10.4329/wjr.v12.i10.213] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
The importance of fluoroscopy as an imaging modality has been minimized relative to other cross-sectional modalities, including high-resolution computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound. Fluoroscopy examinations have decreased in clinical practice due to reduced appreciation of its usefulness, insufficient training of residents, fewer staff with adequate expertise, and poor reimbursements relative to other modalities. We revisit and build upon the prior literature and history of this decreased utilization. We then seek to prove continued value, through categorized examples and within multiple subspecialties, wherein fluoroscopy plays an integral part toward clinical diagnoses as well as optimizing patient outcomes. This is particularly true for motility and esophageal disorders, where structure and function with real-time evaluation is essential. We additionally show several post-operative cases where the synergy of fluoroscopy with CT and endoscopy is apparent. The fluoroscopic radiologist also has the unique ability to vary patient positioning, as opposed to traditional CT or MRI, where orthogonal views are employed without positional or temporal changes. We turn attention to the modern era, with synergistic and novel cases demonstrating that fluoroscopy remains instrumental toward achieving a diagnosis alongside other modalities. Our cases stress the need to maintain expertise in fluoroscopy skill, and underline its continued importance in residency training programs. We conclude that fluoroscopy is a relatively inexpensive modality that is often under-appreciated in diagnostic radiology. We suggest that competency in fluoroscopy is crucial for future generations of radiologists to both work with their peers, as well as to aid clinicians in the optimal treatment of patients.
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Affiliation(s)
- Nathaniel Erez Shalom
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, MD 21205, United States
| | - Gary X Gong
- Department of Neuroradiology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, United States
| | - Martin Auster
- Department of Radiology, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, United States
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