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Faure JM, Larroque-Devigne A, Forgues D, Mousty E, Couture A, Kalfa N, Prodhomme O, Fuchs F. Performance of Prenatal Ultrasound Screening for the Relative Positioning of Mesenteric Vessels. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 39257306 DOI: 10.1002/jum.16576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/14/2024] [Accepted: 08/26/2024] [Indexed: 09/12/2024]
Abstract
OBJECTIVES Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies. METHODS Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist. RESULTS The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery. CONCLUSION This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.
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Affiliation(s)
- Jean Michel Faure
- Department of Obstetrics and Gynecology, University Hospital Center, Montpellier, France
| | - Anne Larroque-Devigne
- Department of Obstetrics and Gynecology, University Hospital Center, Montpellier, France
| | - Dominique Forgues
- Department of Abdominal and Urologic Surgery, CHU Montpellier, Hôpital Lapeyronie, Montpellier, France
| | - Eve Mousty
- Department of Obstetrics and Gynecology, University Hospital Center, Nîmes, France
| | - Alain Couture
- Department of Pediatric Imaging, CHU Montpellier, Montpellier, France
| | - Nicolas Kalfa
- Department of Abdominal and Urologic Surgery, CHU Montpellier, Hôpital Lapeyronie, Montpellier, France
| | - Olivier Prodhomme
- Department of Pediatric Imaging, CHU Montpellier, Montpellier, France
| | - Florent Fuchs
- Department of Obstetrics and Gynecology, University Hospital Center, Montpellier, France
- Inserm, CESP Center for research in Epidemiology and Population Health, U1018, Reproduction and Child Development, Villejuif, France
- Desbret Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France
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Jia XH, Kong S, Gao XX, Cong BC, Zheng CN. Intestinal malrotation complicated with gastric cancer: A case report. World J Clin Cases 2024; 12:210-216. [PMID: 38292641 PMCID: PMC10824180 DOI: 10.12998/wjcc.v12.i1.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/22/2023] [Accepted: 12/15/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Intestinal malrotation is a congenital defect of embryonic development caused by various teratogenic factors. In this condition, the intestinal tube, along with the superior mesenteric artery serving as the axis for the counterclockwise movement, is incomplete or abnormally rotated due to incomplete attachment of the mesentery and abnormal intestinal tube position. Such a case is usually asymptomatic and thus difficult to detect. Therefore, similar variant malformations are only found during an operation required for other abdominal diseases. CASE SUMMARY An elderly male patient was admitted to the hospital due to gastric cancer. An abdominal computed tomography (CT) scan with contrast revealed that the ascending and descending colon were parallel on the right side of the abdominal cavity, while the sigmoid colon extended into the right iliac fossa, allowing the diagnosis of congenital midgut malrotation. Following thorough preoperative preparation, the patient underwent laparoscopic radical gastrectomy to treat his gastric cancer. Intraoperatively, an exploration of the abdominal cavity uncovered the absence of the transverse colon. The distal colon at the hepatic flexure, along with the ascending colon, extended into the right iliac fossa, where it continued as the sigmoid colon. As planned, the laparoscopic radical gastrectomy was performed, and the patient was discharged from the hospital 7 d after the surgery. CONCLUSION Asymptomatic intestinal malrotation is best detected by CT, requiring no treatment but possibly interfering with the treatment of other diseases.
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Affiliation(s)
- Xiang-Hao Jia
- School of Clinical Medicine, Weifang Medical University, Weifang 261053, Shandong Province, China
| | - Shuai Kong
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Xin-Xin Gao
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Bi-Cong Cong
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Chun-Ning Zheng
- Department of Gastrointestinal Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
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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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Huerta CT, Saberi RA, Lynn R, Ramsey WA, Gilna GP, Parreco JP, Sola JE, Perez EA, Thorson CM. Outcomes after Ladd Procedures for Intestinal Malrotation in Newborns with Heterotaxy Syndrome. J Pediatr Surg 2023; 58:1095-1100. [PMID: 36941169 DOI: 10.1016/j.jpedsurg.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 02/19/2023]
Abstract
PURPOSE Intestinal malrotation may be asymptomatic in patients with heterotaxy syndrome (HS), and whether these newborns benefit from prophylactic Ladd procedures is unknown. This study sought to uncover nationwide outcomes of newborns with HS receiving Ladd procedures. METHODS Newborns with malrotation were identified from the Nationwide Readmission Database (2010-2014) and stratified into those with and without HS utilizing ICD-9CM codes for situs inversus (759.3), asplenia or polysplenia (759.0), and/or dextrocardia (746.87). Outcomes were analyzed using standard statistical tests. RESULTS 4797 newborns with malrotation were identified, of which 16% had HS. Ladd procedures were performed in 70% overall and more common in those without heterotaxy (73% vs. 56% HS). Ladd procedures in newborns with heterotaxy were associated with higher complications compared to those without HS including surgical site reopening (8% vs. 1%), sepsis (9% vs. 2%), infections (19% vs. 11%), venous thrombosis (9% vs. 1%), and prolonged mechanical ventilation (39% vs. 22%), all p < 0.001. HS newborns were less frequently readmitted with bowel obstructions (0% vs. 4% without HS, p < 0.001) with no readmissions for volvulus in either group. CONCLUSION Ladd procedures in newborns with heterotaxy were associated with increased complications and cost without differences in rates of volvulus and bowel obstruction on readmission. TYPE OF STUDY Retrospective Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Carlos Theodore Huerta
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Royi Lynn
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Parreco
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Saba TG, Geddes GC, Ware SM, Schidlow DN, Del Nido PJ, Rubalcava NS, Gadepalli SK, Stillwell T, Griffiths A, Bennett Murphy LM, Barber AT, Leigh MW, Sabin N, Shapiro AJ. A multi-disciplinary, comprehensive approach to management of children with heterotaxy. Orphanet J Rare Dis 2022; 17:351. [PMID: 36085154 PMCID: PMC9463860 DOI: 10.1186/s13023-022-02515-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/04/2022] [Indexed: 11/10/2022] Open
Abstract
Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.
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Affiliation(s)
- Thomas G Saba
- Department of Pediatrics, Pulmonary Division, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, USA.
| | - Gabrielle C Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephanie M Ware
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathan S Rubalcava
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terri Stillwell
- Department of Pediatrics, Infectious Disease Division, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Anne Griffiths
- Department of Pediatrics, Pulmonary/Critical Care Division, Children's Minnesota and Children's Respiratory and Critical Care Specialists, Minneapolis, MN, USA
| | - Laura M Bennett Murphy
- Department of Pediatrics, Division of Pediatric Psychiatry and Behavioral Health, University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Andrew T Barber
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Margaret W Leigh
- Department of Pediatrics, Division of Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Necia Sabin
- Heterotaxy Connection, Eagle Mountain, UT, USA
| | - Adam J Shapiro
- Department of Pediatrics, McGill University Health Centre Research Institute, Montreal, QC, Canada
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Raju AS, Benjamin AT, Seppey R, Lambrakis P. Congenital intestinal malrotation with abdominal cocoon and duodenal stricture in an adult. ANZ J Surg 2022; 92:2751-2752. [PMID: 35128777 DOI: 10.1111/ans.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Abdus Salam Raju
- Acute Care Surgery Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | | | - Romain Seppey
- Acute Care Surgery Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Paul Lambrakis
- Acute Care Surgery Unit, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Svetanoff WJ, Srivatsa S, Diefenbach K, Nwomeh BC. Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population. Semin Pediatr Surg 2022; 31:151141. [PMID: 35305800 DOI: 10.1016/j.sempedsurg.2022.151141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Intestinal malrotation is a congenital anomaly that can be associated with midgut volvulus, requiring an emergent operation in order to maintain blood supply to the compromised intestine. It results from an abnormal rotation of the intestines, leading to three types of malrotation. Non-rotation is complete failure of the intestines to rotate, while the most common configuration is associated with the cecum in the mid-upper abdomen, close to a malpositioned duodenal-jejunal (DJ) flexure. This configuration has a narrow mesentery that has a high risk of volvulus. The final form of malrotation is incomplete rotation, where the DJ flexure and cecum are malpositioned, but the mesentery is not narrowed. The benefits of performing a Ladd's procedure for these individuals is controversial. Workup for malrotation should be considered in all patients who present with abdominal pain/distention and bilious emesis. An upper gastrointestinal contrast study is 93-100% sensitive and will show a corkscrew appearance when a volvulus is present. While the basic tenets of the Ladd's procedure have not changed and include detorsion of a volvulus, adhesiolysis of Ladd's bands and broadening of the mesentery, how this is accomplished and in whom are controversial. Laparoscopic Ladd's is associated with shorter hospital stays but also has a higher incidence of recurrent volvulus compared to an open approach. Patients with heterotaxy syndrome also represent a controversial group with some studies showing no difference in post-operative complications despite a higher mortality due to underlying cardiac disease, while other studies show a low incidence of volvulus and question the need for Ladd's in those who are asymptomatic. This review highlights the major aspects of diagnosing and treating malrotation, including the pathophysiology, workup, surgical options and areas of controversy.
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Affiliation(s)
- Wendy Jo Svetanoff
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205
| | - Shachi Srivatsa
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210
| | - Karen Diefenbach
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210.
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Splenic torsion in the setting of polysplenia syndrome. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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9
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Son J, Lee S, Kim W, Jung SM, Jeon TY, Yoo SY, Kim JH, Seo JM. Abnormal Orientation of the Superior Mesenteric Vessels Detected in Asymptomatic Infants: What Is Its Destiny? Front Pediatr 2021; 9:665448. [PMID: 34178885 PMCID: PMC8226012 DOI: 10.3389/fped.2021.665448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasonography (USG) has been described as an alternative diagnostic tool for malrotation that evaluates the orientation of the superior mesenteric vessels. However, literature concerning the management of patients who do not have abdominal symptoms is limited. We aimed to review the clinical course of infants showing abnormal orientation of the superior mesenteric vessels on USG who were asymptomatic at the time of diagnosis. Methods: Seventy asymptomatic infants with abnormal orientation of the superior mesenteric vessels in a single center between 2014 and 2018 were retrospectively analyzed. Results: The 70 patients, 21 underwent upper gastrointestinal series (UGIS) and 11 underwent abdominal surgery for other surgical conditions. Among the 32 (45.7%) patients who underwent UGIS or abdominal surgery, 11 were proven to have malrotation. Of the 38 (54.3%) patients who did not undergo UGIS or abdominal surgery, six patients were too unstable to undergo UGIS, five died due to cardiac complications, and the remaining patient developed midgut volvulus and died 3 days after emergency surgery. The remaining 32 patients who did not undergo UGIS or abdominal surgery were discharged without additional tests, and all were asymptomatic until their last follow-up. In the multivariate analysis, history of heart surgery and the presence of more than three anomalies were significantly associated with malrotation. Conclusion: A significant number of malrotation were diagnosed in asymptomatic infants with abnormal orientation of the superior mesenteric vessels on USG. Infants with major cardiac or multiple anomalies need special attention and should undergo UGIS in a promptly manner to confirm malrotation.
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Affiliation(s)
- Joonhyuk Son
- Department of Pediatric Surgery, Hanyang University College of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wontae Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Min Jung
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So-Young Yoo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong-Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Joshi BM, Singh S, Kumar A, Sandhu MS, Rana D. Situs Ambiguous Anomaly during Laparoscopic Cholecystectomy in an Adult Female. Niger J Surg 2020; 26:72-77. [PMID: 32165841 PMCID: PMC7041347 DOI: 10.4103/njs.njs_47_183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/06/2019] [Accepted: 03/08/2019] [Indexed: 11/21/2022] Open
Abstract
Situs anomalies are rare structural defects affecting 0.01% of general population. They present with multisystem structural defects mostly involving cardiovascular, respiratory and GI systems. Situs abnormality with presence of multiple spleen is termed as left atrial isomerism with anatomical and structural differences to its countertype situs ambiguous with asplenia (right atrial isomerism). In this case report, we present an adult case of situs ambiguous anomaly which was diagnosed incidentally during laparoscopic cholecystectomy. The patient had enlarged left lobe of liver, multiple splenules on right side, malrotated small and large gut, interrupted inferior vena cava with azygos continuation, and bilateral bilobed lungs. It is concluded that variations in situs ambiguous cases differ and a single description is not possible. It is crucial to reveal these variations by using imaging modalities and being aware of them prior to surgery and invasive intervention to prevents the possible risks and complications.
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Affiliation(s)
- Brij Mohan Joshi
- Department of General Surgery, Government Medical College, Amritsar, Punjab, India
| | - Sumitoj Singh
- Department of General Surgery, Government Medical College, Amritsar, Punjab, India
| | - Ashok Kumar
- Department of General Surgery, Government Medical College, Amritsar, Punjab, India
| | - Mandeep Singh Sandhu
- Department of General Surgery, Government Medical College, Amritsar, Punjab, India
| | - Deepak Rana
- Department Radiology, Government Medical College, Amritsar, Punjab, India
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11
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Singh S, Joshi B, Kumar A, Sandhu M, Rana D. Situs ambiguous anomaly during laparoscopic cholecystectomy in an adult female. Niger J Surg 2020. [DOI: 10.4103/njs.njs_47_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Mathis L, Shafer B, Crethers D, Polimenakos AC. Standardized Approach to Intervention for Intestinal Malrotation in Single Ventricle Patients with Heterotaxy Syndrome: Impact on Interstage Attrition and Time to Superior Cavopulmonary Connection. Pediatr Cardiol 2019; 40:1224-1230. [PMID: 31240371 DOI: 10.1007/s00246-019-02136-w] [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: 05/21/2019] [Accepted: 06/13/2019] [Indexed: 01/19/2023]
Abstract
Heterotaxy syndrome (HS) is a significant determinant of outcome in single ventricle (SV) physiology. Attrition rate and time-related events associated with intestinal malrotation (IM) are, yet, to be determined. We sought to evaluate hospital and interstage outcomes in relation with operative intervention for IM (IMO). Twelve SV/HS patients, who underwent IMO, from January 2004 to December 2016, were studied. Early shunt failure, time to superior cavopulmonary connection (SCPC) and interstage attrition were assessed. Since September 2014, based on a comprehensive standardized protocol, IMO was performed at the time of hospitalization for stage-I palliation (S1P) irrespective of clinical manifestations. Patients were assigned to Group A (n = 8): expectant /symptoms-driven versus Group B (n = 4): protocol-driven. At S1P 7 had systemic-to-pulmonary shunt (SPS), 1 SPS with anomalous pulmonary venous return (APVR) repair (Group A) compared to 2 SPS, 1 SPS with APVR repair and 1 Norwood operation (Group B). Median duration from S1P to IMO was 82 days (range 57-336; Group A) compared to 14 days (range 11-31; Group B); p < 0.05. Median age at IMO was 87 days (range 8-345) [Group A: 99 days (range 68-345) vs Group B: 25 days (range 8-39)] (p < 0.05). Early SPS failure occurred in 25% (2 of 8) for Group A compared to none in Group B (p < 0.05). Hospital mortality following IMO was 25% [Group A: 37.5% (3 of 8) vs Group B: 0; p < 0.05]. Interstage survival was 67% [Group A: 50% (4 of 8) vs Group B: 100%; p < 0.05]. Time to SCPC following S1P was 186 days (range 169-218) for Group A compared to 118 days (range 97-161) (Group B); p < 0.05. Operative intervention for IM in SV/HS is associated with significant interstage attrition and might impact the time to SCPC. SPS is at risk for early failure after IMO. A comprehensive standardized concept can mitigate detrimental implications.
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Affiliation(s)
- Lauren Mathis
- Division of Pediatric and Congenital Cardiothoracic Surgery, Children's Hospital of Georgia, 1120 15th Street BAA 8300, Augusta, GA, 30912, USA
| | - Brendan Shafer
- Division of Pediatric and Congenital Cardiothoracic Surgery, Children's Hospital of Georgia, 1120 15th Street BAA 8300, Augusta, GA, 30912, USA
| | | | - Anastasios C Polimenakos
- Division of Pediatric and Congenital Cardiothoracic Surgery, Children's Hospital of Georgia, 1120 15th Street BAA 8300, Augusta, GA, 30912, USA.
- Department of Surgery, Medical College of Georgia, Augusta, GA, USA.
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Arcus C, Sennaiyan U, Trivedi A, Alahakoon TI. Antenatal ultrasound diagnosis of small bowel non-rotation in complex left isomerism: a case report. Int J Surg Case Rep 2019; 56:32-36. [PMID: 30822676 PMCID: PMC6393701 DOI: 10.1016/j.ijscr.2018.11.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 11/18/2022] Open
Abstract
A rare case of mixed isomerism and antenatally diagnosed non-rotation of bowel is reported. Features of bowel non-rotation should be sought antenatally in cases of isomerism. Mixed isomerism and postnatal sequelae should be considered when right and left sided pathology coexist.z
Presentation of case A multiparous expectant mother was referred to our tertiary unit at 23 weeks with a complex fetal cardiac anomaly in the context of suspected heterotaxy syndrome. The cardiac findings were consistent with isomerism: the fetal cardiac position was levocardia with a single functioning double outlet ventricle and AV valve, pulmonary stenosis, and interrupted inferior vena cava (IVC) with azygous continuation. The fetal abdominal situs was also altered, with the stomach to the right, and the hepatobiliary system midline to left. The spleen was not identified antenatally or postnatally. At 36 weeks, ultrasound revealed an abnormal bowel pattern with small bowel loops on the right side of the abdomen and large bowel on the left, suggesting a diagnosis of non- rotation. The infant was delivered vaginally at 39 weeks. The cardiac diagnosis and non-rotation of the small bowel were confirmed by postnatal echocardiography and contrast fluoroscopy. Discussion Heterotaxy syndrome is traditionally classified into right or left isomerism depending on how and where the organs are anatomically arranged. The case presented here demonstrates mixed laterality and prenatal ultrasound features of non-rotation. Conclusion It is important to be informed of the embryological variants of isomerism and actively seek antenatal evidence of bowel non-rotation in such cases.
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Affiliation(s)
- Charles Arcus
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, NSW, 2145, Australia; The University of Sydney, Sydney Medical School, Sydney, NSW, Australia.
| | - Usha Sennaiyan
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, NSW, 2145, Australia
| | - Amit Trivedi
- Grace Centre for Newborn Care, Westmead Children's Hospital, Sydney, NSW, 2145, Australia.
| | - Thushari I Alahakoon
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Sydney, NSW, 2145, Australia; The University of Sydney, Sydney Medical School, Sydney, NSW, Australia.
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Abstract
More children with congenital heart disease are surviving and require noncardiac surgery. A high-yield summary of congenital heart anatomy and pathophysiology is presented to contextualize these patients for surgeons. Preoperative planning including risk stratification, anesthetic management and timing of elective surgery are discussed. Specific intraoperative considerations for particular cases, such as the use of laparoscopy and thoracic surgery, are reviewed. Postoperative outcomes and recommended management required to mitigate complications are summarized.
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Affiliation(s)
| | - J Craig Egan
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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Baban A, Cantarutti N, Adorisio R, Lombardi R, Calcagni G, Piano Mortari E, Dallapiccola B, Marino B, Iorio FS, Carsetti R, Digilio MC, Giannico S, Drago F, Carotti A. Long-term survival and phenotypic spectrum in heterotaxy syndrome: A 25-year follow-up experience. Int J Cardiol 2018; 268:100-105. [DOI: 10.1016/j.ijcard.2018.02.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/03/2018] [Accepted: 02/13/2018] [Indexed: 11/29/2022]
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Selevany M, Guerrero M, Perrone JA, Hussain M. Acute appendicitis in a patient with heterotaxy syndrome. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Malrotation is not associated with adverse outcomes after cardiac surgery in patients with heterotaxy syndrome. J Pediatr Surg 2018; 53:1494-1498. [PMID: 29453132 DOI: 10.1016/j.jpedsurg.2018.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/18/2017] [Accepted: 01/15/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with heterotaxy syndrome (HS) often have asymptomatic malrotation. There is a lack of consensus regarding the management of these patients, particularly in patients with complex congenital heart disease (CHD). We sought to describe the prevalence of malrotation and incidence of volvulus in a population of patients with complex CHD and to identify the impact of malrotation on morbidity and mortality following cardiac surgery. METHODS We performed a retrospective review of all patients with HS and complex CHD who required cardiac surgery in the first year of life at a single center between October 1995 and September 2015. Malrotation was diagnosed by abdominal imaging or by direct inspection during abdominal surgery. Demographic data was collected along with details of hospitalization following cardiac and GI surgeries. Descriptive analysis along with appropriate hypothesis testing was conducted to evaluate the results. RESULTS We identified 49 patients with HS, 42 with single ventricle anatomy and 7 with biventricular anatomy. Of the 49 patients, 29 (59%) were diagnosed with malrotation, 6 (12%) had normal intestinal rotation, and 14 (29%) had no evaluation of intestinal rotation. The prevalence of malrotation in the population who underwent abdominal imaging was 29 out of 35 (83%). There was no difference in survival following cardiac surgery between patients with malrotation and those with unknown or normal intestinal anatomy. Comparing patients with malrotation and patients with normal or unknown intestinal rotation, there was also no difference in surrogate markers of morbidity. Of the 29 patients with known malrotation, only 2 patients (7%) underwent therapeutic Ladd procedures and 19 (65%) underwent prophylactic Ladd procedures. CONCLUSIONS We conclude that the outcomes following cardiac surgery for patients with HS are not impacted by the presence of malrotation. Furthermore, we also found that the incidence of volvulus in the studied group is low. Given these findings, and the understanding that patients with HS and significant CHD are frequently tenuous and high risk surgical candidates, we do not believe performing prophylactic Ladd procedures is warranted. LEVEL OF EVIDENCE III.
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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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Is Screening of Intestinal Foregut Anatomy in Heterotaxy Patients Really Necessary?: A Systematic Review in Search of the Evidence. Ann Surg 2017; 264:1156-1161. [PMID: 26704743 DOI: 10.1097/sla.0000000000001563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE (1) Is screening of intestinal rotational anatomy obligatory in "asymptomatic" patients with heterotaxy? (2) Does detection of an anomaly warrant surgical correction? SUMMARY OF BACKGROUND DATA Heterotaxy is an abnormal arrangement of thoraco-abdominal viscera across a left-to-right axis. Intestinal rotational anomalies are frequent among patients with heterotaxy, but debate exists as to whether they are benign in nature, requiring careful observation alone, or if surgical correction is warranted to prevent obstruction or midgut volvulus. METHODS A systematic review [according to PRISMA guidelines] was conducted using CINAHL, EMBASE, Medline, and Cochrane Databases. Article quality was assessed using MINORS criteria. Conference proceedings and unpublished data were screened additionally. RESULTS Nineteen studies met the eligibility criteria but reporting was adequate for 9. All were observational studies. These included a total of 414 patients managed expectantly, that is, "asymptomatic patients" in whom no intestinal rotation screening was undertaken (group A), 191 cases in whom screening was performed routinely (group B), and 92 patients considered "symptomatic" of potential rotational anomalies and therefore underwent imaging or laparotomy (group C). In group A, 1 patient developed symptoms attributable to malrotation in whom laparotomy confirmed the diagnosis (0.24%). Among groups B and C, 151 had Ladd's operations (53%) and 14 cases of malrotation with obstruction or volvulus were described (4.9%), of which 2 "symptomatic patients" died before laparotomy. Overall surgical complication rate was 17% with 30-day mortality rate of 2.6% to 4.6%. CONCLUSION The evidence base for screening "asymptomatic" patients is weak especially considering the life-limiting comorbidities.
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21
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Characteristics of Hospitalizations for the Glenn Procedure in Those With Isomerism Compared to Those Without. Pediatr Cardiol 2016; 37:1409-1415. [PMID: 27393478 DOI: 10.1007/s00246-016-1449-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
Isomerism, also known as heterotaxy, is a unique clinical entity in which there are mirror imaged findings in the thoracic. In the abdomen, the arrangement of organs can be random. The anatomic findings also have functional consequences. Isomerism has been known to increase morbidity and mortality in those with functionally univentricular hearts. The aim of this study was to determine the impact of isomerism on the Glenn hospitalization. Data from the 1997 to 2012 Kids' Inpatient Database were utilized for this cross-sectional study. Admissions during which a Glenn procedure was done were identified. Next, these admissions were separated into those with and without isomerism. Admission characteristics were then compared in a univariate fashion as well as by regression analysis. Length of hospitalization, cost of hospitalization, extracorporeal membrane oxygenation, and inpatient mortality were the outcomes of interest. A total of 4959 admissions with a Glenn procedure were identified. Of these, 450 were associated with isomerism. The median age at which the Glenn procedure was done was 10 and 13 months in those without and with isomerism, respectively. Neither univariate nor regression analysis demonstrated any significant difference in length of hospitalization, cost of hospitalization, need for extracorporeal membrane oxygenation, and inpatient mortality between those with and without isomerism. Isomerism does not impact the characteristics of the Glenn hospitalization. Those with isomerism did tend to be older when they underwent the Glenn procedure.
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22
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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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Teele SA, Jacobs JP, Border WL, Chanani NK. Heterotaxy Syndrome: Proceedings From the 10th International PCICS Meeting. World J Pediatr Congenit Heart Surg 2016; 6:616-29. [PMID: 26467876 DOI: 10.1177/2150135115604470] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A session dedicated to heterotaxy syndrome was included in the program of the Tenth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, Florida in December 2014. An invited panel of experts reviewed the anatomic considerations, surgical considerations, noncardiac issues, and long-term outcomes in this challenging group of patients. The presentations, summarized in this article, reflect the current approach to this complex multiorgan syndrome and highlight future areas of clinical interest and research.
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Affiliation(s)
- Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Johns Hopkins All Children's Heart Institute, All Children's Hospital, Saint Petersburg and Tampa, FL, USA
| | - William L Border
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhil K Chanani
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Evaluating a management strategy for malrotation in heterotaxy patients. J Pediatr Surg 2016; 51:859-62. [PMID: 26968699 DOI: 10.1016/j.jpedsurg.2016.02.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/07/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND There 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. METHODS We 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. RESULTS We 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. CONCLUSION Eleven 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.
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Tan YW, Khalil A, Kakade M, Carvalho JS, Bradley S, Cleeve S, Giuliani S. Screening and Treatment of Intestinal Rotational Abnormalities in Heterotaxy: A Systematic Review and Meta-Analysis. J Pediatr 2016; 171:153-62.e1-3. [PMID: 26868865 DOI: 10.1016/j.jpeds.2015.12.074] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/20/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the role of screening and prophylactic surgery for intestinal rotational abnormalities (IRAs) in asymptomatic patients with heterotaxy. STUDY DESIGN 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. RESULTS 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%). CONCLUSION 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.
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Affiliation(s)
- Yew-Wei Tan
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, Division of Developmental Science, St George's University of London, London, United Kingdom
| | - Madhavi Kakade
- Department of Pediatric and Neonatal Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Julene S Carvalho
- Fetal Medicine Unit, Division of Developmental Science, St George's University of London, London, United Kingdom; Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Sarah Bradley
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Stewart Cleeve
- Department of Pediatric and Neonatal Surgery, Royal London Hospital, London, United Kingdom
| | - Stefano Giuliani
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom.
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Gottschalk I, Stressig R, Ritgen J, Herberg U, Breuer J, Vorndamme A, Strizek B, Willruth A, Geipel A, Gembruch U, Berg C. Extracardiac anomalies in prenatally diagnosed heterotaxy syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:443-449. [PMID: 25847110 DOI: 10.1002/uog.14871] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/29/2015] [Accepted: 03/31/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To assess the incidence and impact of extracardiac anomalies on the prognosis of fetuses with heterotaxy syndrome. METHODS All fetuses diagnosed with heterotaxy syndrome by three experienced examiners over a period of 14 years (1999-2013) were reviewed retrospectively. RESULTS In total, 165 fetuses with heterotaxy syndrome were diagnosed in the study period. One hundred and fifty (90.9%) had cardiac defects; extracardiac anomalies that did not involve the spleen were present in 26/165 (15.8%) cases. Of the total study cohort, termination of pregnancy was performed in 49 (29.7%) cases, intrauterine death occurred in 11 (6.7%), postnatal death occurred in 38 (23.0%) and 67 (40.6%) were alive at the latest follow-up, resulting in a total perinatal and pediatric mortality of 59.4%. Among the 105 liveborn neonates, 15 (14.3%) had extracardiac anomalies with significant impact on the postnatal course: one neonate died following repair of an encephalocele, six had successful treatment for various types of intestinal malrotation and/or atresia and one underwent hiatal hernia repair; the remaining seven had biliary atresia, of which five died and the two survivors are awaiting liver transplantation. The status of the spleen was assessed in 93/105 liveborn children and was found to be abnormal in 84/93 (90.3%). There were three cases of lethal sepsis, all associated with asplenia. Of the 38 postnatal deaths, 29 (76.3%) had a cardiac cause, seven (18.4%) had an extracardiac cause and in two (5.2%) the reason was uncertain. CONCLUSIONS Although the leading causes of death in fetuses and children with heterotaxy syndrome are cardiac, a small subset of fetuses have extracardiac anomalies with significant impact on outcome. These anomalies often escape prenatal detection, and therefore neonates at risk should be monitored for bowel obstruction, biliary atresia and immune dysfunction in order to allow timely intervention through a multidisciplinary approach. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Gottschalk
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Gynecology and Obstetrics, University of Köln, Köln, Germany
| | - R Stressig
- praenatal.de, Prenatal Medicine and Genetics, Köln, Germany
- Congenital Cardiac Center ('Deutsches Kinderherzzentrum'), Sankt Augustin, Germany
| | - J Ritgen
- praenatal.de, Prenatal Medicine and Genetics, Köln, Germany
| | - U Herberg
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - J Breuer
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - A Vorndamme
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - B Strizek
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - A Willruth
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - A Geipel
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - U Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - C Berg
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Gynecology and Obstetrics, University of Köln, Köln, Germany
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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Loomba RS, Ahmed MM, Spicer DE, Backer CL, Anderson RH. Manifestations of bodily isomerism. Cardiovasc Pathol 2016; 25:173-180. [PMID: 26872066 DOI: 10.1016/j.carpath.2016.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/27/2015] [Accepted: 01/10/2016] [Indexed: 01/12/2023] Open
Abstract
We report the findings present in 49 postmortem specimens from patients with so-called heterotaxy, concentrating on those found in the extracardiac systems of organs. Also known as bodily isomerism, we suggest that it is important to segregate the syndromes into their isomeric subtypes to be able to make inferences regarding likely extracardiac and intracardiac findings to allow for proper surveillance. We demonstrate that this is best done on the basis of the atrial appendages, which were isomeric in all the hearts obtained from the specimens available for our inspection. The abdominal organs do not demonstrate isomerism, and they show variable features when compared to the isomeric atrial appendages.
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Affiliation(s)
- Rohit S Loomba
- Children's Hospital of Wisconsin, Medical College of Wisconsin, 9000 Wisconsin Avenue, Milwaukee, WI.
| | - Muhammad M Ahmed
- Ziauddin University, 4/B, Shahrah-e-Ghalib, Block 6, Clifton, Karachi, 75600, Pakistan
| | - Diane E Spicer
- University of Florida Department of Pediatric Cardiology, 1600 SW Archer Road, Gainesville, FL; Johns Hopkins All Children's Heart Institute, 501 6th Avenue, St. Petersburg, FL
| | - Carl L Backer
- Lurie Children's Hospital, Feinberg School of Medicine, 225 E Chicago Avenue, Chicago, IL
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Central Parkway, Newcastle upon Tyne, Tyne and Wear NE1 3BZ, United Kingdom
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Cullis PS, Siminas S, Salim A, Johnson R, Losty PD. Heterotaxy and intestinal rotation anomalies: 20 years experience at a UK regional paediatric surgery centre. Pediatr Surg Int 2015; 31:1127-31. [PMID: 26243388 DOI: 10.1007/s00383-015-3755-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND 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. METHODS Medical case record reviews of ALL heterotaxy patients born during January 1993-December 2013 and attending a UK paediatric centre were analyzed. RESULTS 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). CONCLUSION This study strongly supports a 'watchful waiting' policy for heterotaxy patients. Many children who ultimately die from heart disease may avoid unnecessary abdominal surgery.
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Affiliation(s)
- Paul S Cullis
- Department of Surgical Paediatrics, The Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
| | - Sotirios Siminas
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Adeline Salim
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Robert Johnson
- Department of Paediatric Cardiology, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK. .,Institute of Child Health, University of Liverpool, Liverpool, UK.
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Landisch R, Abdel-Hafeez AH, Massoumi R, Christensen M, Shillingford A, Wagner AJ. Observation versus prophylactic Ladd procedure for asymptomatic intestinal rotational abnormalities in heterotaxy syndrome: A systematic review. J Pediatr Surg 2015; 50:1971-4. [PMID: 26358665 DOI: 10.1016/j.jpedsurg.2015.08.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The management of intestinal rotational abnormalities (IRA) in heterotaxy syndrome (HS) remains inconsistent. Because of the high incidence of malrotation in HS, screening of asymptomatic patients is standard of care in some institutions. The Ladd procedure is the treatment for malrotation, and has been reported to have high complication rates in HS patients. METHODS We performed a systematic review of publications describing IRA in pediatric HS patients from January 1993 to present. The incidence of volvulus on surgical exploration was determined. Perioperative and long-term outcomes were analyzed to determine complication and mortality rates. RESULTS Eleven retrospective studies describing 649 HS patients were identified. Of all patients with HS, 27% (176/649) underwent Ladd procedure. Only 1.2% (8/649) of HS patients included had volvulus. Postoperative complications occurred in 25 patients (14%), including a 10% incidence of small bowel obstruction. Perioperative and overall mortality rates after Ladd procedure were 3% and 21%, respectively. Six studies described mesenteric width, reporting 43% to have narrow mesentery. CONCLUSION The Ladd procedure is not without significant morbidity and mortality in heterotaxy patients. Further prospective studies should investigate predictors of mesenteric width to spare the unnecessary morbidity of surgery in patients who are at low risk for volvulus.
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Affiliation(s)
- Rachel Landisch
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | | | - Roxanne Massoumi
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Melissa Christensen
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Amanda Shillingford
- Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Amy J Wagner
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
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Salavitabar A, Anderson BR, Aspelund G, Starc TJ, Lai WW. Heterotaxy syndrome and intestinal rotational anomalies: Impact of the Ladd procedure. J Pediatr Surg 2015; 50:1695-700. [PMID: 25783348 DOI: 10.1016/j.jpedsurg.2015.02.065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/16/2015] [Accepted: 02/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Children with heterotaxy syndrome and intestinal rotational anomalies (IRA) are at risk for midgut volvulus and ischemia. Controversy exists regarding risks and benefits of prophylactic Ladd procedures. The purpose of this study is to assess the impact of Ladd procedures on adverse events for children with heterotaxy and IRA. METHODS A retrospective cohort study using the Pediatric Health Information System (PHIS) database was performed. All children with heterotaxy and IRA admitted at age ≤ 30 days and discharged between 1/1/2004 and 1/1/2011 were included with a minimum 2-year follow-up period. The primary outcome was major morbidity, defined as a composite variable for intestinal obstruction/volvulus, ischemia, or resection, or inhospital mortality. Univariable and multivariable analyses were performed. RESULTS There were 325 patients who met the inclusion criteria, including 92 (28%) patients with single ventricles. Mean gestational age was 38.0 ± 2.1 weeks and birth weight was 3.1 ± 0.6 kg. Ladd procedure was performed during initial hospitalization on 188 (58%) children. In multivariable analyses, Ladd procedure on initial hospitalization was associated with a 2.2 times increased odds of adverse events on subsequent admissions (95% CI 1.3-4.0, p = 0.007). CONCLUSIONS Ladd procedure is associated with increased odds of adverse events for children with heterotaxy and IRA.
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Affiliation(s)
- Arash Salavitabar
- Department of Pediatrics, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 630W 168th St.-VC 507, New York, NY 10032, USA.
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CH 2N, New York, NY 10032, USA.
| | - Gudrun Aspelund
- Division of Pediatric Surgery, Columbia University Medical Center, 3959 Broadway, CH 2N, New York, NY 10032, USA.
| | - Thomas J Starc
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CH 2N, New York, NY 10032, USA.
| | - Wyman W Lai
- Division of Pediatric Cardiology, Columbia University Medical Center, 3959 Broadway, CH 2N, New York, NY 10032, USA.
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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: 74] [Impact Index Per Article: 8.2] [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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Garcelan-Trigo JA, Tello-Moreno M, Rabaza-Espigares MJ, Talavera-Martinez I. Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e17853. [PMID: 26557278 PMCID: PMC4632560 DOI: 10.5812/iranjradiol.17853v2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/21/2014] [Accepted: 04/26/2014] [Indexed: 02/07/2023]
Abstract
Adult midgut volvulus is a challenging diagnosis because of its low incidence and nonspecific symptoms. Diagnostic delay and long-term complaints are frequent in this clinical scenario. We reported a patient referred to our diagnostic imaging unit with intermittent abdominal pain, bloating and episodic vomiting for several years. He underwent barium gastrointestinal transit and abdominal ultrasound, which revealed severe gastric dilatation, food retention and slow transit until a depressed duodenojejunal flexure, with malrotation of the midgut and jejunal loops being located in the right upper quadrant. Computed tomography angiography was performed, showing rotation of the small intestine around the mesentery root, suggestive of midgut malrotation. In addition, an abnormal twisted disposition of superior mesenteric artery with corkscrew appearance was seen, shaping the pole-barber sign which was evident in volume rendering three-dimensional reconstructions. The patient underwent scheduled surgical treatment without any complication and had good outcome after hospital discharge and follow-up. Computed tomography plays an important role in evaluation of adult midgut volvulus. In addition, angiographic reconstructions can help us to assess the anatomic disposition of mesenteric vascular supply. Both of these assessments are useful in preoperative management.
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Affiliation(s)
- Juan Arsenio Garcelan-Trigo
- Diagnostic Imaging Unit, Hospital San Agustin, Linares (Jaen), Spain
- Corresponding author: Juan Arsenio Garcelan Trigo, Diagnostic Imaging Unit, Hospital San Agustin, Linares (Jaen), Spain. Tel: +34-618177483, E-mail:
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Abstract
PURPOSE OF REVIEW At present, there is a debate as to the management of malrotation in pediatric patients. This review highlights recent literature including the role of laparoscopy, and the management of asymptomatic patients with and without congenital cardiac disease. RECENT FINDINGS Symptomatic patients are still recommended to undergo open Ladd's procedure. Laparoscopic Ladd's procedure in asymptomatic patients confers a shorter time to tolerating feeds, shorter length of stay, and a decreased rate of bowel obstruction and other complications. It may, however, carry a higher risk of postoperative volvulus. Diagnostic laparoscopy is recommended in asymptomatic patients in whom the diagnosis is uncertain on upper gastrointestinal imaging. Asymptomatic patients with congenital heart disease may be managed with initial observation or operation, based upon individualized risk benefit assessment. If an elective Ladd's procedure is performed, it should take place after palliative cardiac operations have resulted in stable cardiac function. Screening upper gastrointestinal studies in heterotaxy patients may be unnecessary as the reported rates of volvulus in recent studies are low. SUMMARY Laparoscopic Ladd's procedure may be an acceptable alternative to an open procedure for asymptomatic patients. Observation of asymptomatic patients with congenital cardiac disease is a reasonable alternative in selected patients.
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An unusual cause of duodenal obstruction in adults. Arab J Gastroenterol 2015; 16:63-5. [PMID: 25910574 DOI: 10.1016/j.ajg.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/20/2014] [Accepted: 03/16/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Intestinal malrotation refers to a spectrum of anomalies of midgut rotation and fixation at various stages during early embryonic development. In adults, malrotation manifests itself mainly in chronic non-specific abdominal complaints and may therefore be easily misdiagnosed beyond infancy. CASE PRESENTATION We present a case of an 82-year-old Caucasian man with vomiting and abdominal pain owing to malrotation complicated by duodenal obstruction and intestinal ischaemia confirmed by radiologic evaluation and autopsy report. CONCLUSION Although intestinal malrotation is generally discovered near birth, our case demonstrates that physicians should consider this diagnosis at advanced age as well. In addition, particularly radiologic findings are supportive in diagnosing malrotation.
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Heterotaxy syndrome infants are at risk for early shunt failure after Ladd procedure. Ann Thorac Surg 2015; 99:918-25. [PMID: 25595831 DOI: 10.1016/j.athoracsur.2014.09.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/19/2014] [Accepted: 09/23/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac-specific risks and complications after a Ladd procedure in patients with heterotaxy syndrome (HS) and intestinal rotational anomalies (IRA) are unknown. We sought to (1) describe rates of hospital mortality and early systemic-to-pulmonary (S-P) artery shunt failure after the Ladd procedure in patients with HS and (2) explore risk factors associated with early shunt failure in patients with HS with single ventricle (SV). METHODS This retrospective study included all Ladd procedures performed from January 1999 to December 2012 in patients with HS at a single center. Risk factors investigated for early S-P artery shunt failure included birth weight, gestational age, sex, age at and timing of Ladd procedure relative to cardiac operations, and shunt type. RESULTS Ladd procedure was performed on 54 infants with HS and congenital heart disease. Hospital mortality for the entire cohort was 5.6% (3 of 54 patients). Early shunt failure occurred in 19% (4 of 21) of HS infants with SV. Mean preoperative blood urea nitrogen (BUN) levels were higher in HS infants with early shunt failure (20 versus 12.5 mg/dL; p = 0.054). CONCLUSIONS Patients with SV and HS with S-P artery shunts are at risk for early shunt failure after a Ladd procedure. A higher mean preoperative BUN level is noted in patients with HS and early shunt failure. Careful risk-benefit analysis is indicated before recommending routine elective Ladd procedures in patients with HS.
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Sulkowski JP, Cooper JN, Duggan EM, Balci O, Anandalwar S, Blakely ML, Heiss K, Rangel SJ, Minneci PC, Deans KJ. Early versus delayed surgical correction of malrotation in children with critical congenital heart disease. J Pediatr Surg 2015; 50:86-91. [PMID: 25598100 PMCID: PMC4298705 DOI: 10.1016/j.jpedsurg.2014.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD). METHODS Patients 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. RESULTS Of 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. CONCLUSIONS In patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eileen M Duggan
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Ozlem Balci
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Seema Anandalwar
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Kurt Heiss
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Shawn J Rangel
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
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The role of screening and prophylactic surgery for malrotation in heterotaxy patients. J Pediatr Surg 2014; 49:1746-8. [PMID: 25487475 DOI: 10.1016/j.jpedsurg.2014.09.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 09/05/2014] [Indexed: 01/01/2023]
Abstract
PURPOSE There are no standardized guidelines for screening or management of malrotation in Heterotaxy Syndrome (HS). We sought to review our experience to determine if evidenced based guidelines could be drafted. METHODS A retrospective chart review was performed at our freestanding children's hospital on all patients under one year of age undergoing a Ladd procedure between 2000 and 2011. In addition, all Heterotaxy patients were reviewed during this period. RESULTS Twenty-three Heterotaxy patients and seventy-nine Non-Heterotaxy patients underwent a Ladd procedure. Both groups had a high rate of complication. Heterotaxy was associated with significantly higher mortality 30days after Ladd procedure. In our review, we also identified seventy-six HS patients who did not undergo a Ladd procedure. Among these patients, fourteen had normal intestinal anatomy, five had malrotation, and fifty-seven were never evaluated for intestinal malrotation. No patients with intestinal malrotation or unknown intestinal rotation status suffered midgut volvulus. Average follow-up time was 5.1years. CONCLUSIONS We conclude that prophylactic Ladd procedures in children with Heterotaxy are associated with a high morbidity and mortality. Patients who avoided screening were not exposed to a significant risk of midgut volvulus, and our experience suggests that routine screening of Heterotaxy patients for malrotation should be abandoned.
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Abstract
Management of complex congenital heart disease in patients with Heterotaxy syndrome (HS) has steadily improved. However, there is an insufficient appreciation of various non-cardiac issues that might impact the overall status of these patients. This article briefly reviews the implications of gastrointestinal, immunologic, genitourinary, respiratory, and central nervous system involvement in HS patients with a view to aid in their comprehensive clinical management.
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Affiliation(s)
- Shyam S Kothari
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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40
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Tackett JJ, Muise ED, Cowles RA. Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency. World J Radiol 2014; 6:730-736. [PMID: 25276316 PMCID: PMC4176790 DOI: 10.4329/wjr.v6.i9.730] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 04/15/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The most accurate and practical imaging algorithm for the diagnosis of intestinal malrotation can be a complex and sometimes controversial topic. Since 1900, significant advances have been made in the radiographic assessment of infants and children suspected to have anomalies of intestinal rotation. We describe the current methods of abdominal imaging of malrotation along with their pros and cons. When associated with volvulus, malrotation is a true surgical emergency requiring rapid diagnosis and treatment. We emphasize the importance of close cooperation and communication between radiology and surgery to perform an effective and efficient diagnostic evaluation allowing prompt surgical decision making.
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Hill SJ, Heiss KF, Mittal R, Clabby ML, Durham MM, Ricketts R, Wulkan ML. Heterotaxy syndrome and malrotation: does isomerism influence risk and decision to treat. J Pediatr Surg 2014; 49:934-7; discussion 937. [PMID: 24888838 DOI: 10.1016/j.jpedsurg.2014.01.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Controversy remains regarding the management of the asymptomatic heterotaxy syndrome (HS) patient with suspected intestinal rotational abnormalities. We evaluated the outcomes for our HS population to identify frequency of malrotation and identify characteristics of children who might benefit from expectant management. METHODS After IRB approval, a retrospective review of all patients treated for HS at a large tertiary care children's hospital between January 2008 and June 2012 was performed. For the purpose of this paper, malrotation was defined as an operative note that described the presence of Ladd's bands and a narrow mesentery. RESULTS Thirty-eight patients with HS were identified, including 18 who underwent abdominal exploration. Left atrial isomerisation (LAI) was identified in 13 individuals, and right atrial isomerisation (RAI) was noted in 25. The rate of surgical intervention did not vary between the 2 groups (54%). Malrotation was found in 8 patients: one with LAI and 7 with RAI. This difference in incidence was statistically significant (p=0.04). CONCLUSION These data suggest that the direction of atrial isomerisation influences the likelihood of true malrotation, where RAI patients are more likely to be malrotated. Given the inherent risk of surgery on this medically fragile patient population, surgeons should consider expectant management for asymptomatic LAI patients.
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Affiliation(s)
- Sarah J Hill
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA
| | - Kurt F Heiss
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA
| | - Rohit Mittal
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA
| | - Martha L Clabby
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Cardiology, Atlanta, GA, USA
| | - Megan M Durham
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA
| | - Richard Ricketts
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA
| | - Mark L Wulkan
- Emory University and Children's Healthcare of Atlanta, Division of Pediatric Surgery, Atlanta, GA, USA.
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Newman B, Koppolu R, Murphy D, Sylvester K. Heterotaxy syndromes and abnormal bowel rotation. Pediatr Radiol 2014; 44:542-51. [PMID: 24419494 DOI: 10.1007/s00247-013-2861-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/20/2013] [Accepted: 12/15/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bowel rotation abnormalities in heterotaxy are common. As more children survive cardiac surgery, the management of gastrointestinal abnormalities has become controversial. OBJECTIVE To evaluate imaging of malrotation in heterotaxy with surgical correlation and provide an algorithm for management. MATERIALS AND METHODS Imaging reports of heterotaxic children with upper gastrointestinal (UGI) and/or small bowel follow-through (SBFT) were reviewed. Subsequently, fluoroscopic images were re-reviewed in conjunction with CT/MR studies. The original reports and re-reviewed images were compared and correlated with surgical findings. RESULTS Nineteen of 34 children with heterotaxy underwent UGI, 13/19 also had SBFT. In 15/19 reports, bowel rotation was called abnormal: 11 malrotation, 4 non-rotation, no cases of volvulus. Re-review, including CT (10/19) and MR (2/19), designated 17/19 (90%) as abnormal, 10 malrotation (abnormal bowel arrangement, narrow or uncertain length of mesentery) and 7 non-rotation (small bowel and colon on opposite sides plus low cecum with probable broad mesentery). The most useful CT/MR findings were absence of retroperitoneal duodenum in most abnormal cases and location of bowel, especially cecum. Abnormal orientation of mesenteric vessels suggested malrotation but was not universal. Nine children had elective bowel surgery; non-rotation was found in 4/9 and malrotation was found in 5/9, with discrepancies (non-rotation at surgery, malrotation on imaging) with 4 original interpretations and 1 re-review. CONCLUSION We recommend routine, early UGI and SBFT studies once other, urgent clinical concerns have been stabilized, with elective laparoscopic surgery in abnormal or equivocal cases. Cross-sectional imaging, usually obtained for other reasons, can contribute diagnostically. Attempting to assess mesenteric width is important in differentiating non-rotation from malrotation and more accurately identifies appropriate surgical candidates.
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Affiliation(s)
- Beverley Newman
- Department of Radiology, Stanford University, Lucile Packard Children's Hospital, 725 Welch Road, MC 5913, Stanford, CA, 94305, USA,
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Birnbaum DJ, Geffroy Y, Goin G, Balandraud P. Left side appendicitis with midgut malrotation in an adult. J Surg Tech Case Rep 2014; 5:38-40. [PMID: 24470850 PMCID: PMC3889003 DOI: 10.4103/2006-8808.118627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Midgut malrotation (MMR) is a congenital anomaly referring to either nonrotation or incomplete rotation of the primitive intestinal loop around the axis of the superior mesenteric artery during fetal development. Adult MMR is rare and majority of MMR in adults remains asymptomatic throughout life. The increasing use of diagnostic imaging for acute abdominal pain will lead to more incidental recognitions of MMR. Up to now, surgical treatment has been guided by the experience from pediatric surgery, and Ladd's procedure has been the treatment of choice in adults with MMR. However, a major dilemma arises when patients are essentially asymptomatic and incidentally diagnosed with MMR during another abdominal affection like acute appendicitis. The surgeon has to decide whether it is necessary to also treat the MMR. Here, we report a rare case of a 37-year-old patient with acute left side appendicitis in association with asymptomatic MMR. We discuss whether correction of the asymptomatic malrotation was indicated.
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Affiliation(s)
- David Jérémie Birnbaum
- Department of Visceral and Thoracic Surgery, Hôpital d'Instruction des Armées A. Laveran, Marseille Armées, France
| | - Yann Geffroy
- Department of Radiology, Hôpital d'Instruction des Armées A. Laveran, Marseille Armées, France
| | - Géraldine Goin
- Department of Visceral and Thoracic Surgery, Hôpital d'Instruction des Armées A. Laveran, Marseille Armées, France
| | - Paul Balandraud
- Department of Visceral and Thoracic Surgery, Hôpital d'Instruction des Armées A. Laveran, Marseille Armées, France
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Amula V, Ellsworth GL, Bratton SL, Arrington CB, Witte MK. Heterotaxy syndrome: impact of ventricular morphology on resource utilization. Pediatr Cardiol 2014; 35:38-46. [PMID: 23797157 DOI: 10.1007/s00246-013-0736-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/04/2013] [Indexed: 11/30/2022]
Abstract
Patients with heterotaxy syndrome (HS) have significant cardiac and extracardiac anomalies that impact outcome. To improve the management of this complex patient population, we performed a comprehensive analysis of their anatomic and clinical features along with an evaluation of resource utilization data. The objectives were to describe anatomic and clinical features of patients with HS syndrome treated at a single center from 1992 to 2011 focusing on the impact of ventricular morphology (univentricular [UV] vs. biventricular [BV]) on clinical outcomes and resource utilization. Clinical and echocardiographic data from patients with HS were abstracted from medical records. Health care costs were indexed to inflation. Seventy-eight patients were identified with HS ranging in age from 1 day to 29 years old. UV morphology was present in 46 patients (59 %), most commonly with right-ventricular dominance (36 of 46). The presence of extra cardiac anomalies did not differ between the UV and BV groups (82 vs. 78 %) nor did morbidities, such as need for enteral tube feedings (47 vs. 25 %) or pacemaker placement (24 vs. 25 %). Mortality was 28 % in the entire cohort: 39 % in univentricuar patients versus 10.5 % in those with biventricular anatomy. Hospital length of stay for medical illnesses was similar in both groups, but length of stay after surgery was significantly longer in UV than BV patients. Among survivors, UV patients had greater median hospital costs (TeX 67,732, p < 0.001), but when this was adjusted for mortality and variable follow-up, there were no differences in health care costs within the first year of life. Significant health care dollars are used to manage children with HS, the majority of which involve expenses related to surgical care. Although patients with biventricular morphology have better survival, morbidity and resource utilization are similar to those for UV patients especially within the first year of life.
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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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Massive hemorrhage after Kasai portoenterostomy in a patient with a congenital extrahepatic portosystemic shunt, malrotation and a double aortic arch: report of a case. Surg Today 2013; 44:1561-4. [PMID: 23657644 DOI: 10.1007/s00595-013-0605-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 02/25/2013] [Indexed: 10/26/2022]
Abstract
A newborn female was transferred to our hospital presenting with severe respiratory distress. She underwent tracheal intubation and nasogastric tubing. Investigations revealed a congenital extrahepatic portosystemic shunt (CEPS) type 1, biliary atresia, heterotaxia, polysplenia, malrotation and a double aortic arch (DAA). She underwent the Kasai portoenterostomy and the Ladd procedure when she was 29 days old. On postoperative day 20, she developed sudden hematemesis with bright red blood. Endoscopy showed massive bleeding from an esophageal ulcer, and endoscopic therapy was performed successfully. During left thoracotomy, an aortoesophageal fistula (AEF) was detected and repaired by direct suturing. The postoperative course was uneventful. CEPS type 1 is commonly associated with other congenital malformations; however, there have been no previous reports of an association between CEPS and DAA. Nasogastric tube insertion in a patient with DAA can result in catastrophic AEF. The treatment strategy should be carefully considered in patients with CEPS type 1 and multiple congenital fetal anomalies.
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Jie BS, Kim EO, Kim JS, Lee HJ, Song YM, Kim Y, Jung SH, Oh JH. [Midgut volvulus in a 70-year-old man due to intestinal nonrotation]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2013; 61:282-285. [PMID: 23756671 DOI: 10.4166/kjg.2013.61.5.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Intestinal malrotation is a congenital disorder that results from the failure of normal bowel rotation and fixation during the 5th gestational week. The incidence of intestinal malrotation is <0.2%, but prompt diagnosis is important because this anomaly can cause midgut volvulus and lead to fatalities. Compared to infants presenting with acute symptoms, such as abdominal pain, vomiting, or diarrhea, adult patients complain of intermittent self-limited abdominal pain. We present a case of intestinal malrotation complicated by midgut volvulus improved with conservative care in a 70-year-old man. The diagnosis was suggested on the basis of imaging findings.
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Affiliation(s)
- Byung-Soo Jie
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Sharma MS, Guleserian KJ, Forbess JM. Ladd's procedure in functional single ventricle and heterotaxy syndrome: does timing affect outcome? Ann Thorac Surg 2013; 95:1403-7; discussion 1407-8. [PMID: 23434253 DOI: 10.1016/j.athoracsur.2012.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 11/07/2012] [Accepted: 11/12/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND Infants with univentricular hearts often require intervention, such as a systemic to pulmonary shunt, as part of a staged surgical palliation. This physiology is inherently unstable, and interim mortality ranges from 4% to 15%. Heterotaxy syndrome confers a high incidence of intestinal rotation and fixation abnormalities. Controversy persists as to the need for elective Ladd's procedure. The purpose of this study is to review our experience in children with heterotaxy syndrome and functionally univentricular hearts who underwent Ladd's procedure. METHODS A retrospective chart review (2005 to 2010) from our institutional database identified patients with heterotaxy syndrome who underwent a Ladd's procedure. RESULTS Nine patients (3 boys and 6 girls) underwent Ladd's procedure. Patient demographics were as follows: median gestational age, 38 weeks (range, 37 to 39); median birth weight, 2.7 kg (range, 2 to 3.4 kg); and median age at Ladd's procedure, 180 days (range, 7 to 1,080). Four patients (44%) exhibited feeding intolerance with documented intestinal rotation and fixation abnormalities. Two of these patients underwent Ladd's procedure before cardiac surgery, 1 of whom had subsequent pulmonary artery banding, had recurrent necrotizing enterocolitis, and died. Two children had Ladd's procedure after initial cardiac palliation; both had shunt thrombosis during abdominal surgery, with a mortality of 50%. Five patients who were asymptomatic underwent Ladd's procedure after second-stage palliation. Mortality in this group was 0%. CONCLUSIONS Ladd's procedure in single ventricle heterotaxy patients who are tolerating enteral feeding should be performed after physiologic palliation to a more balanced circulation, ideally after cavopulmonary connection. Symptomatic neonates pose management challenges. Timing of abdominal surgery should be carefully considered, given the significant risk of mortality in these patients.
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Affiliation(s)
- Mahesh S Sharma
- University of Texas Southwestern School of Medicine and Children's Medical Center of Dallas, Dallas, Texas, USA.
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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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Papillon S, Goodhue CJ, Zmora O, Sharma SS, Wells WJ, Ford HR, Upperman JS, Wang KS, Bushman GA, Kim R, Pierce JR. Congenital heart disease and heterotaxy: upper gastrointestinal fluoroscopy can be misleading and surgery in an asymptomatic patient is not beneficial. J Pediatr Surg 2013; 48:164-9. [PMID: 23331810 DOI: 10.1016/j.jpedsurg.2012.10.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/13/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Heterotaxy syndrome is associated with intestinal abnormalities. We sought to define the gastrointestinal anatomy and determine both the risk of volvulus and benefit of screening upper gastrointestinal fluoroscopy (UGI) in these patients. METHODS Medical records from 2003 until 2011 at Children's Hospital Los Angeles were reviewed in patients with heterotaxy for cardiovascular diagnosis, gastrointestinal symptoms, imaging and surgical arrangement of viscera, perioperative morbidities, and overall mortality. RESULTS 224 patients were identified. Fifteen had polysplenia, 41 had asplenia, 50 had normal splenic morphology, 13 had inversus, and 104 were uncharacterized. UGI was performed in 4 patients for suspected volvulus and 20 for obstructive symptoms. Sixty-two had "screening" UGIs. Of 138 asymptomatic patients without imaging, none developed volvulus during the study period. In 30 patients with duodenojejunal malposition (DJM) who underwent surgery, none had malrotation or narrow mesentery. Eleven developed complications, with 8 requiring reoperation for obstruction. Of 8 patients with malrotation, 7 received a Ladd's procedure, and 2 had volvulus with viable bowel. One patient required reoperation and resection for obstruction. CONCLUSION While rotational abnormalities are common in heterotaxy, risk of volvulus is low. Following operation, the risk of bowel obstruction and of need for reoperation is higher. We advocate avoiding operation in the asymptomatic patient.
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Affiliation(s)
- Stephanie Papillon
- Department of Pediatric Surgery, Children's Hospital Los Angeles, CA 90027, USA
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