Laparoscopic treatment of intestinal malrotation in neonates and infants: retrospective study

Intestinal malrotation in neonates or infants may require urgent surgical treatment, especially when volvulus and vascular compromise of the midgut are suspected. Successful laparoscopic management of malrotation has been described in a number of case reports. It remains unclear, however, whether laparoscopy for the treatment of malrotation has a success rate equal to that of open surgery and what relative risks exist in terms of conversion and redo surgery in larger numbers of patients. This report describes a retrospective analysis of the clinical outcome for 45 children who underwent laparoscopic treatment of intestinal malrotation at the authors' institution. The 45 patients in this series, ages several days to 13 years, underwent a diagnostic laparoscopy for suspected intestinal malrotation. For 37 patients, malrotation with or without volvulus was diagnosed. All these patients underwent laparoscopic derotation and Ladd's procedure. Successful laparoscopic treatment of intestinal malrotation could be performed in 75% of the cases (n = 28), and conversion to an open procedure was necessary in 25% of the cases (n = 9). The median hospital stay was 11 days (range, 2-60 days). Postoperative clinical relapse due to recurrence of malrotation, volvulus, or both occurred for 19% of the laparoscopically treated patients (n = 7). These patients underwent laparoscopic (n = 1) or open (n = 6) redo surgery. Diagnostic laparoscopy is the procedure of choice when intestinal malrotation is suspected. If present, malrotation can be treated adequately with laparoscopic surgery in the majority of cases. Nevertheless, to prevent recurrence of malrotation or volvulus, a low threshold for conversion to an open procedure is mandated

Biliary atresia

Biliary atresia (BA) is a rare disease characterised by a biliary obstruction of unknown origin that presents in the neonatal period. It is the most frequent surgical cause of cholestatic jaundice in this age group. BA occurs in approximately 1/18,000 live births in Western Europe. In the world, the reported incidence varies from 5/100,000 to 32/100,000 live births, and is highest in Asia and the Pacific region. Females are affected slightly more often than males. The common histopathological picture is one of inflammatory damage to the intra- and extrahepatic bile ducts with sclerosis and narrowing or even obliteration of the biliary tree. Untreated, this condition leads to cirrhosis and death within the first years of life. BA is not known to be a hereditary condition. No primary medical treatment is relevant for the management of BA. Once BA suspected, surgical intervention (Kasai portoenterostomy) should be performed as soon as possible as operations performed early in life is more likely to be successful. Liver transplantation may be needed later if the Kasai operation fails to restore the biliary flow or if cirrhotic complications occur. At present, approximately 90% of BA patients survive and the majority have normal quality of life

Disorders of intestinal rotation and fixation (“malrotation”)

Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46708/1/247_2004_Article_1279.pd

Má rotação intestinal em adulto, relato de caso e revisão da literatura Adult intestinal malrotation, case report and literature review

INTRODUÇÃO: Má rotação intestinal é entidade clínico-cirúrgica que faz parte do cotidiano do cirurgião pediátrico, mas que se torna um desafio diagnóstico quando desenvolve sintomas em adolescentes e adultos. RELATO DO CASO: Mulher deu entrada no hospital com quadro de intensa dor abdominal com três dias de evolução e piora progressiva nas últimas 24 horas. A dor apresentava piora importante após as refeições, quando era acompanhada de náuseas e vômitos. Ao exame físico apresentava-se em bom estado gera, abdômen plano, flácido, ruídos presentes, levemente doloroso à palpação de epigástrio, mas sem sinais de irritação peritoneal. Exames laboratoriais encontravam-se dentro dos limites da normalidade, bem como estudo ultrassonográfico. Não houve melhora clínica apesar do tratamento instituído e optou-se por investigação cirúrgica por tomografia sugerir má rotação intestinal. No intra-operatório observou-se todo o intestino delgado disposto para o lado direito do abdômen e o cólon para o lado esquerdo. Além disto, o jejuno proximal encontrava-se isquêmico e fazendo um volvo de 720º sobre o eixo dos vasos mesentéricos superiores. Para a correção da anomalia fez-se enterotomia do jejuno proximal, a cerca de 10 cm do ligamento de Treitz, e desconfecção do volvo, o que cursou com melhora progressiva da isquemia intestinal, permitindo que se fizesse enteroanastomose. Realizou-se ligadura do pedículo da artéria cólica média em sua origem e colectomia direita seguida de anastomose íleo-transversa látero-lateral. A paciente evolui bem. CONCLUSÃO: - A má rotação intestinal em adultos é doença de difícil diagnóstico primário, devido a não constar entre as hipóteses diagnósticas iniciais do cirurgião geral.<br>INTRODUCTION: Intestinal malrotation is a clinical surgical entity that is present in the everyday practice of the pediatric surgeon. However, it becomes a diagnostic challenge when symptoms develop in adolescents and adults. CASE REPORT: A woman presented to the hospital with intense abdominal pain of three days' duration and progressive worsening over the preceding 24 hours. The pain increased markedly after meals, accompanied by nausea and vomiting. On physical examination, the patient was in good general health, her abdomen was flat, flaccid, with normal bowel sounds, and tender to palpation of the epigastrium, yet with no signs of peritoneal irritation. Laboratory test results were within the limits of normal, as was ultrasonography. No clinical improvement was achieved despite the treatment instituted; surgical exploration was chosen as tomography was suggestive of intestinal malrotation. Intraoperatively, all the small intestine was found to be positioned to the right side of the abdomen and the colon, to the left side. In addition, the proximal jejunum was ischemic and forming a volvulus of 720º over the axis of the superior mesenteric vessels. In order to correct the anomaly, enterotomy of the proximal jejunum was performed at approximately 10 cm from the ligament of Treitz, and the volvulus was corrected. This promoted a progressive improvement of the intestinal ischemia, which made enteroanastomosis possible. The middle colic artery pedicle was ligated at its root and a right colectomy was performed, followed by a side-to-side ileo-transverse anastomosis. The patient is doing well. CONCLUSION: Intestinal malrotation in adults is a condition of difficult primary diagnosis, since it is not among the initial diagnostic hypotheses of the general surgeon