Congenital intestinal malrotation presenting in octogenarians: a report of two cases

Malrotation in an Adult Patient With Pneumoperitoneum Following Nissen-Sleeve Gastrectomy: A Case Report

Intestinal malrotation is typically encountered in the first year of life and is rarely seen in adult populations. Herein, we present the case of a 48-year-old woman with a surgical history of laparoscopic Nissen-sleeve gastrectomy before 11 months who was referred to the general surgery service after presenting to the emergency department with acute epigastric abdominal pain for one-day duration. Radiography and a computed tomography (CT) scan of the abdomen revealed a large pneumoperitoneum. Subsequently, a diagnostic laparoscopy was performed, which detected a sealed perforation in the fundus of the wrapped-sleeved stomach, along with an incidental finding of intestinal malrotation. The encountered variation of anatomy created an intraoperative challenge during the conversion from Nissen-Sleeve gastrectomy to single anastomosis gastric bypass. The diagnosis of intestinal malrotation in adults is often overlooked, posing substantial diagnostic and management challenges when encountered.

Intestinal malrotation complicated with gastric cancer: A case report

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.

Surgical management of congenital malrotation presenting in adulthood

Intestinal malrotation is characterised by positional and congenital fixation abnormalities resulting from a failure in embryonic development in the normal 270° rotation around the axis of the superior mesenteric artery. Intestinal malrotation is primarily thought to affect neonates with an incidence of 1 in 500, however, only 1 in 6000 live births are symptomatic, and these usually present within the first month of life in 40% of cases and within the first year in over 5% of cases as an obstructive pathology or volvulus. In adults, however, the incidence has been documented at 0.2%. These patients usually present with postprandial symptoms that are intermittent such as bilious emesis, abdominal pain and malabsorption. Rarely, adults with congenital malrotation may present with acute obstruction due to volvulus, however, less than 100 adult cases are described in the literature. A high index of suspicion is required to identify cases of malrotation in the adult patient which leads to delays in diagnosis and therefore increases in morbidity can be seen.

Emergent initial presentation of congenital malrotation with midgut volvulus in 68-year-old

Congenital malrotation is a pathology nearly exclusive to the infant population. In the rare instance when it is diagnosed in an adult, it is typically associated with a longstanding history of gastrointestinal symptoms. Unfortunately, this unique presentation in an unexpected population has the potential to be confounding, leading to delayed or mismanaged care. Here, we describe an intriguing case of congenital malrotation complicated by midgut volvulus in a 68-year-old woman. Even more curious, the patient did not have a medical history plagued by abdominal complaints. Careful, comprehensive evaluation yielded appropriate surgical management via Ladd's procedure and right hemicolectomy in this complex patient.

Unique coexistence of chronic midgut malrotation, mesenteric cyst, and pancreas divisum in a Crohn's disease patient: MR-enterography assessment

Chronic midgut malrotation is a rare condition found in the adult age that predisposes to severe complications. It derives from an incomplete rotation of the mesentery around the superior mesenteric artery during embryogenic development. This results in intestinal loops displacement and mesenteric malfixation. Nevertheless, other congenital abnormalities can be also associated, such as mesenteric cysts and biliopancreatic malformations. Imaging modalities employed in the evaluation of chronic midgut malrotation include contrast radiography, which permits to visualize the localization of the intestinal loops, and ultrasound, that can detect a twist of superior mesenteric vessels. Computed tomography is however considered the modality of choice, owing to its wide field of view and the rapid scan times. The role of magnetic resonance imaging in this field has been barely explored. In particular, magnetic resonance enterography has a consolidated role in the assessment of intestinal loops and allows detecting extra-intestinal findings as well. Moreover, the lack of radiation exposure makes this technique suitable for nonemergency cases, especially in young patients. This is the first description of simultaneous chronic midgut malrotation, mesenteric cyst and pancreas divisum discovered in a Crohn's disease patient. The performance of magnetic resonance enterography allowed to properly interpret this multifaceted clinical picture.