1. Malrotation in Older Children and Adults
Patrick Phelan
12/3/2009

2. Malrotation
“the condition is rare enough so that it is likely to escape the mind, and it is common enough to be important.”
William Ladd 1932

3. Embryology Week 5: Gut herniates from abdominal wall
Rotation: always CCW (looking at fetus)
Duodenojejunal segment rotates 90° twice (180°)
Cecocolic segment rotates 90° twice (180°)
Week 10-11: Gut returns to abdominal cavity
Duodenojejunal segment rotates 90° again (270°)
Cecocolic segment rotates 90° again (270°)

4. Normal orientation of the mesentary!!
Embryology
90°
90°
90°
Normal orientation of the mesentary!!

5. Happy Blimp

6. Abnormalities of Rotation
Nonrotation
Bowel loops rotate less than 90° total
Incomplete rotation
Rotation occurs, but less than 270° total

7. Sad Blimp

8. Volvulus
Mesenteric twisting results in transient or persistent vascular occlusion
Ischemia
Necrosis
Perforation
Sepsis

9. Ladd’s Procedure Detorsion of volvulus if present.
Division of Ladd’s cecal bands
Division of interloop bands – widen mesentery
Appendectomy
Relocation of the bowel

10. Clinical Settings We all know: What about: Infant with bilious emesis
Emergent UGI (and Ladd’s procedure)
What about:
Adolescents/Adults with positive UGI/BE/CT
w/ vague hx vomiting, abdominal pain, malabsorption
Found at ex-lap for other reason
Truly Incidental malrotation
CT for abdominal trauma
BE for colon cancer screening

11. Evidence Retrospective Case Series Administrative Database Data
Decision Tree Modeling

12. Retrospective Case Series
Prasil (2000):
Single Institution retrospective case series
Methods: all patients operated on for malrotation (as a primary condition) 1980 – 1998.
Exclusion:
high probability associations
Incidental findings at laparotomy
Comparison between those < 2 y/o and >2 y/o

13. Prasil 2000 Results: Table 2. Symptoms at presentation
Table 1. Mode of Clinical Presentation
Table 2. Symptoms at presentation

14. Prasil 2000 Table 3. Surgical Complications
Conclusions: “Based on our review, we support the policy that regardless
of age and even in asymptomatic patients, any malrotation diagnosed should have particular surgical attention.”

15. Malek 2005 Population based study of Administration Database Methods:
KID 2000 (Kid’s Inpatient Discharge)
2.5M discharge summaries from 27 states
Inclusion:
Code for abnormality of intestinal rotation
1< Age <18
Ladd’s procedure component
Exclusion:
Discharge to short-term care facility (avoid double count)
Discharge dx of post-operative small bowel obstruction

16. Malek 2005
Data extrapolated using US census data to predict national number of Ladd’s procedures
Variables of interest
Emergency admission
Transfer
Hospital location(urban/rural)
Teaching status
Dedicated Children’s hospital

17. Malek 2005
Results
771 cases, 219 > 1 year old

18. Malek 2005
75%
19% 4%

19. Malek 2005 25% admitted for treatment of other disease Conclusion:
8 anti-reflux
7 appendectomies
5 diaphragmatic hernias
4 trauma ex-laps
Conclusion:
Although less common in older children, volvulus can occur at all ages and therefore warrants surgical correction

20. Durkin 2008 Single Institution retrospective case series
Methods: all patients seen for malrotation 2002 – 2006
24 patients – 23 underwent Ladd’s procedure
>16 = adult
<16 = pediatric
Age Range: 10 days to 89 years

21. Durkin 2008
Results:
No significant difference in chronicity of symptoms at presentation between children and adults
Subgroup analysis of <2 y/o shows 100% of patients present acutely (50% >2 y/o) p = 0.03

22. Durkin 2008
Results:
Practioners are better at diagnosing Malrotation in Children

23. Durkin 2008 Results: Re-ops:
Postoperative complications are worse in Adults
Re-ops:
Duodenal obstruction 2/2 adhesion in 2 pts
Others: ladd’s not initially performed

24. Malek 2005 (2) Decision analysis model Outcomes
Goal: determine age at which observation is preferable to Ladd’s for ASYMPTOMATIC malrotation.
Methods: Markov decision analysis with 1 year cycles for Asymptomatic malrotation patients >1 y/o
Outcomes
Life expectancy
QALYs – projected decrease in quality of life from operative intervention

26. Malek 2005 (2)
Age related mortality is estimated from patients with colon resection for benign cause.

27. Malek 2005 (2)

28. Malek 2005 (2)
Conclusion:
For truly asymptomatic adults with malrotation, observation is preferred over prophylactic Ladd’s procedure

29. JD 11y M Hx abd pain with N/V for years
Presents with non-bilious vomiting and abdominal pain

30. References Durkin E. J Am Coll Surg (2008) 206: 658–663.
Malek M. The American Journal of Surgery (2006) 191: 45–51
Prasil P. J Pediatr Surg (2000) 35:
Malek M. Journal of Pediatric Surgery (2005) 40, 285–289