Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure

Two exploratory laparotomies within six days: A case of midgut volvulus in an adult with congenital malrotation

INTRODUCTION

Midgut volvulus in adults based on congenital malrotation, which required emergency surgery, may occur under the stimulation of adverse factors and is rare and easy to be misdiagnosed.

PRESENTATION OF CASE

A young male was taken to the emergency room of a local hospital after six hours abdominal pain. Computed tomography (CT) shows intestinal volvulus and exploratory laparotomy was performed. Postoperative CT revealed remission of small intestinal torsion and congenital malrotation of the midgut. The patient vomited frequently within 48 h after the surgery, and was transferred to our hospital for conservative treatment. After 4 days of conservative treatment, the vomiting symptoms were relieved at first, but worsened again after a liquid diet. CT showed complete duodenal obstruction and exploratory laparotomy was performed again. Congenital malrotation was found, which resulted in midgut volvulus and duodenal obstruction due to anomalous fixation of the mesentery. The bowel was placed in normal anatomical position, and the mesentery was sutured to the posterior abdominal wall. The patient was followed up for 24 months with no complaints.

DISCUSSION

Due to the rare incidence and atypical pain clinical manifestations, it is difficult for the congenital malrotation in adults to be diagnosed. Midgut volvulus in adults with malrotation is even rarer and requires emergency operation, and may be misdiagnosed.

CONCLUSION

Midgut volvulus with midgut malrotation is very rare in adults. Exploratory laparotomy must be careful to reduce misdiagnosis and recurrence of volvulus.

Diagnostic accuracy of upper gastrointestinal series in children with suspected intestinal malrotation

Intestinal malrotation (IM) results from an altered or incomplete rotation of the fetal midgut around the superior mesenteric artery axis. The abnormal anatomy of IM is associated with risk of acute midgut volvulus which can lead to catastrophic clinical consequences. The upper gastro-intestinal series (UGI) is addressed as the gold standard diagnosis procedure, but a variable failure degree has been described in literature. The aim of the study was to analyze the UGI exam and describe which features are the most reproducible and reliable in diagnosing IM. Medical records of patients surgically treated for suspected IM between 2007 and 2020 at a single pediatric tertiary care center were retrospectively reviewed. UGI inter-observer agreement and diagnostic accuracy were statistically calculated. Images obtained with antero-posterior (AP) projections were the most significant in terms of IM diagnosis. Duodenal-Jejunal Junction (DJJ) abnormal position resulted to be the most reliable parameter (Se = 0.88; Sp = 0.54) as well as the most readable, with an inter-reader agreement of 83% (k = 0.70, CI 0.49-0.90). The First Jejunal Loops (FJL), caecum altered position and duodenal dilatation could be considered additional data. Lateral projections demonstrated an overall low sensitivity (Se = 0.80) and specificity (Sp = 0.33) with a PPV of 0.85 and a NPV of 0.25. UGI on the sole AP projections ensures a good diagnostic accuracy. The position of the third portion of the duodenum on lateral views showed an overall low reliability, therefore it was not helpful but rather deceiving in diagnosing IM.

IMPOWER: a national patient-generated registry for intestinal malrotation exploring diagnosis, treatment, and surgical outcomes

BACKGROUND

Intestinal malrotation is a rare congenital condition with potentially devastating consequences due to potential volvulus and massive intestinal necrosis. Diagnosis is often delayed and long-term symptoms following surgical correction are poorly characterized. We developed the Intestinal Malrotation Patient Outcomes and WEllness Registry (IMPOWER), a national patient-generated registry (PGR), to capture data related to presenting symptoms, testing, diagnosis, treatment, and follow-up of individuals diagnosed with malrotation. IMPOWER captures patient-reported information from adult patients and parents/caregivers of children diagnosed with malrotation at the time of enrollment and at ongoing 6-month intervals. We present baseline characteristics of patients enrolled during the first two months of the registry.

RESULTS

Within the first two months, 354 patients with malrotation enrolled in IMPOWER, and 191 (53.9%) completed all baseline assessments. Nearly 90% of the 119 pediatric participants and 37.7% of the 72 adult participants experienced symptoms prior to diagnosis. Vomiting was the predominant symptom for pediatric participants compared to abdominal pain in adults. Yellow bilious emesis was more commonly reported than green, and volvulus at diagnosis occurred in 70% of pediatric and 27% of adult participants. One-third of pediatric participants had a bowel resection as part of their initial surgical procedure, resulting in 23.4% with diagnosed short bowel syndrome. More than 60% of pediatric and 80% of adult registrants reported gastrointestinal symptoms that persisted throughout the first year following their initial operation. Approximately 25% of registrants reported visiting four or more gastroenterologists for management of ongoing symptoms.

CONCLUSIONS

Fewer than half of pediatric patients presented with the "classic" presentation of green bilious colored emesis. Yellow bilious emesis was more commonly reported, and chronic gastrointestinal symptoms (i.e., abdominal pain, reflux, constipation, diarrhea) and feeding intolerance were common following surgical procedures for malrotation. This novel PGR highlights the need for a multicenter prospective registry to characterize the natural history and develop consistent standards of care related to the diagnosis, treatment, and long-term care for patients with malrotation.