Management of Intestinal Malrotation in UCSF General Surgery - - PowerPoint PPT Presentation

3/8/2014 1

Management of Intestinal Malrotation in Children vs. Adults

Benjamin Padilla, MD Assistant Professor of Surgery March 2014 Benjamin Padilla, MD Assistant Professor of Surgery March 2014 UCSF General Surgery Division of Pediatric Surgery

Disclosures

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“I have nothing to disclose.”

Midgut volvulus: a surgeon’s dilemma

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Normal Rotation of the Midgut

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3/8/2014 2 Normal Rotation of the Midgut

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“The midgut mesentery is a plane”

Normal Rotation of the Midgut

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1. Duodenum rotates behind SMA Right colon rotates

• ver the top of SMA

2.

Normal Rotation of the Midgut

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Normal Rotation of the Midgut

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AP Lateral

3/8/2014 3 Malrotation of the Midgut

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1. Duodenum fails to cross midline 2. Ladd’s bands form to RUQ

Malrotation of the Midgut

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AP Lateral

Fulcrum for Midgut Volvulus

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Fulcrum for Midgut Volvulus

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Clockwise rotation

• f the midgut

3/8/2014 4 Midgut Volvulus

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AP Lateral

Ladd’s Procedure

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Ladd’s Procedure

1. Counterclockwise de-torsion of the midgut

– “turn back the hands of time”

2. Divide Ladd’s bands 3. Broaden the midgut mesentery 4. Appendectomy 5. Place the midgut in “non-rotated” configuration

– Small bowel >>> Right – Colon >>> Left – Cecum >>> Hypogastric midline

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Ladd’s Procedure is Effective

• 147 patients over 10-year period
• 38 (26%) post-operative complications
• 11 (7.5%) reoperation
• 8 (5.4%) Adhesive SBO
• 1 (0.7%) Volvulus
• Laparoscopic vs Open
• Similar complication rates

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www.elsevier.com/locate/jpedsurg

Journa l of Pediatric Surgery (2011) 46, 1720–1725

Assessment of recurrent abdominal symptoms after Ladd procedure: clinical and radiographic correlation☆,☆

☆ David M. Biko a,b,⁎, S udha A. Anupindi a, S tephanie B. Hanhan a,c, T hane Blinman d, R ichard I. Markowitza

a

Department of Radiology, The Children's Hospital of Philadelphia, Phildelphia, PA 19104, US A

bDepartment of Radiology, National Naval Medical Center, Bethesda, MD 20889, US

A

cDepartment of Radiology, Jersey S

hore University Medical Center, Neptune NJ 07753, US A

dDepartment of General S

urgery, The Children's Hospital of Philadelphia, Phildelphia, PA 19104, US A

3/8/2014 5 Age-related Presentation

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Age at presentation

Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93.

Age-related Presentation

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Duration of symptoms by age

Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93.

Age-related Presentation

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Presenting symptoms by age

Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93.

Management of “Asymptomatic” Malrotation

• Markov decision analysis

Parameters

• Risk of observation: volvulus,

short gut, death

• Risk of operation: death

Treatment recommendation

• QALY gain by either operation
• r observation

Children: Ladd’s procedure should be considered Adults: The risk of midgut volvulus does not justify prophylactic Ladd’s procedure

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“ “ “ “QALY gained by elective Ladd’ ’ ’ ’s Procedure” ” ” ”

Malek and Burd. Am J Surg. 2006 Jan;191(1):45-51.

3/8/2014 6 Summary

• Intestinal malrotation is the primary risk factor for

midgut volvulus

• Clinical presentation varies with age
• Babies: bilious emesis
• Adult: abdominal pain and obstructive symptoms
• Ladd’s procedure effectively prevents midgut volvulus
• All symptomatic patients should have a Ladd’s

procedure

• “Asymptomatic” malrotation is less concerning with age

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Opening February 1, 2014