Malrotation: Age-Related Differences in Reoperation Rate

Abstract

Objective Intestinal malrotation classically presents in the neonatal period with bilious vomiting. However, population studies suggest that up to two-thirds of these patients are diagnosed later in childhood or in adulthood. Increased morbidity in the adult population has been reported. Local experience suggested that surgery was technically more difficult in older children and led to the hypothesis that it would be associated with increased morbidity.

Methods A retrospective case note analysis was performed on all children presenting with intestinal malrotation to a tertiary referral center between January 2002 and November 2014. Case notes and operation records were reviewed and those who underwent laparotomy for confirmed malrotation were included. Children were grouped as infants (< 1 year) and older (> 1 year). The primary outcome was total emergency reoperation rate. Secondary outcomes were requirement for a bypass at reoperation and mortality.

Results A total of 131 children with malrotation were identified (104 infants, 27 older children; 78 males; age range, 0–16 years). Overall, 13 patients had emergency reoperation following initial Ladd procedure (6 infants and 7 older children). Risk for reoperation was significantly higher in older children (p = 0.005) and additionally a bypass procedure was more often required in older children than infants (4 children, 2 infants, p = 0.016). Adhesiolysis was required on four occasions and redo Ladd procedure in two; these were evenly distributed between both groups. One child was found to have distal bowel obstruction at reoperation. There were three deaths (2.3%), all in the infant group. One was directly associated with malrotation with extensive bowel necrosis. The other two died of unrelated sepsis several months later.

Conclusions Malrotation surgery in older children is associated with a significantly higher emergency reoperation rate. The primary duodenal bypass procedure should always be considered with longstanding chronic intermittent obstruction associated with malrotation if the simple Ladd procedure is deemed inadequate.

Keywords

duodenal obstruction - bypass - Ladd procedure

• References

• 1 von Flüe M, Herzog U, Ackermann C, Tondelli P, Harder F. Acute and chronic presentation of intestinal nonrotation in adults. Dis Colon Rectum 1994; 37 (2) 192-198
• 2 Seashore JH, Touloukian RJ. Midgut volvulus. An ever-present threat. Arch Pediatr Adolesc Med 1994; 148 (1) 43-46
• 3 Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children: a 25-year review. Arch Surg 1981; 116 (2) 158-160
• 4 Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg 1993; 17 (3) 326-331
• 5 Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery 2011; 149 (3) 386-393
• 6 Durkin ET, Lund DP, Shaaban AF, Schurr MJ, Weber SM. Age-related differences in diagnosis and morbidity of intestinal malrotation. J Am Coll Surg 2008; 206 (4) 658-663
• 7 Kapfer SA, Rappold JF. Intestinal malrotation-not just the pediatric surgeon's problem. J Am Coll Surg 2004; 199 (4) 628-635
• 8 Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. J Pediatr Surg 1989; 24 (8) 777-780
• 9 Maxson RT, Franklin PA, Wagner CW. Malrotation in the older child: surgical management, treatment, and outcome. Am Surg 1995; 61 (2) 135-138
• 10 Wang CA, Welch CE. Anomalies of intestinal rotation in adolescents and adults. Surgery 1963; 54: 839-855
• 11 Filston HC, Kirks DR. Malrotation-the ubiquitous anomaly. J Pediatr Surg 1981; 16 (4) (Suppl. 01) 614-620
• 12 Fukuya T, Brown BP, Lu CC. Midgut volvulus as a complication of intestinal malrotation in adults. Dig Dis Sci 1993; 38 (3) 438-444
• 13 Matzke GM, Dozois EJ, Larson DW, Moir CR. Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Surg Endosc 2005; 19 (10) 1416-1419
• 14 Daneman A. Malrotation: the balance of evidence. Pediatr Radiol 2009; 39 (Suppl. 02) S164-S166
• 15 El-Gohary Y, Alagtal M, Gillick J. Long-term complications following operative intervention for intestinal malrotation: a 10-year review. Pediatr Surg Int 2010; 26 (2) 203-206
• 16 Shew SB. Surgical concerns in malrotation and midgut volvulus. Pediatr Radiol 2009; 39 (Suppl. 02) S167-S171
• 17 Millar AJ, Rode H, Cywes S. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg 2003; 12 (4) 229-236
• 18 Ladd W. Surgical diseases of the alimentary tract in infants. N Engl J Med 1936; 215: 705-708
• 19 Millar AJW, Rode H, Brown RA, Cywes S. The deadly vomit: Malrotation and midgut volvulus. Pediatr Surg Int 1987; 2 (3) 172-176
• 20 Brennom WS, Bill AH. Prophylactic fixation of the intestine for midgut nonrotation. Surg Gynecol Obstet 1974; 138 (2) 181-184