Time-Driven Activity-Based Cost Comparison of Three Imaging Pathways for Suspected Midgut Volvulus in Children

ObjectiveTo use time-driven activity-based costing to compare the costs of pathways for evaluating suspected pediatric midgut volvulus using either fluoroscopic upper gastrointestinal examination (UGI) or focused abdominal ultrasound (US).MethodsProcess maps were created through patient shadowing, medical record review, and frontline staff interviews. Using time-driven activity-based costing methodology, practical capacity cost rates were calculated for personnel, equipment, and facility costs. Supply costs were included at institutional purchase prices. The cost of each process substep was determined by multiplying step-specific capacity costs by the median time required for each step, and substep costs were summed to generate total pathway cost. Multivariate sensitivity analyses were performed applying minimum and maximum labor costs. Assuming UGI would be used to troubleshoot nondiagnostic US, a break-even analysis was performed to determine the cost impact of varying frequencies of UGI on the total cost of the US-based pathway.ResultsProcess maps were created from 105 (48 girls, 57 boys) patient encounters. Base case pathway times were 90 min (UGI) and 55 min (US). Base case cost for UGI was $282.74 (range: $170.86-$800.82) when performed by a radiology practitioner assistant and $545.66 (range: $260.97-$1,974.06) when performed by a radiologist. Base case cost for US was $155.67 (range: $122.94-$432.29) when performed by a sonographer and $242.64 (range: $147.46-$1,330.05) when performed by a radiologist. For a US-based pathway, the total cost break-even pathway mix (percent UGI required for troubleshooting) was 57%.ConclusionUS can be a faster and less costly alternative to UGI in pediatric patients with suspected midgut volvulus.     

Approach to the baby with bilious vomiting

Bilious vomiting in the term neonate is a cardinal feature of a critical condition – intestinal malrotation – and may herald an impending abdominal crisis. It may also be due to a number of other surgical and medical causes, and there is a significant healthcare burden in excluding malrotation in the neonatal population. Health professionals caring for neonates need a sound knowledge of the assessment, diagnosis, and management of the neonate presenting with bilious vomiting. This review discusses the approach and immediate management, discusses uncertainties in evidence and offers practical advice for healthcare professionals who are faced with a baby with bilious vomiting.     

Laparoscopic Ileocolic Resection for Crohn's Disease Associated With Midgut Malrotation

Midgut malrotation is an anomaly of fetal intestinal rotation. Its incidence in adults is rare. A case of midgut malrotation in a 51-year-old man with complicated Crohn''s disease of the terminal ileum is presented. Symptoms, diagnosis, and treatment are reviewed. Preoperative workup led to correct surgical planning that ultimately allowed a successful laparoscopic resection.     

Malrotation of the Intestine in Adult and Colorectal Cancer

Malrotation of the gut is a congenital anomaly and usually presents in childhood. Rarely, it may present in adults. Patients may be asymptomatic, and malrotation is detected during investigations, operation or autopsy. It can cause longstanding abdominal symptoms like pain, dyspepsia or acute abdomen due to volvulus. In adults, malrotation is found with different gastrointestinal malignancies like gastric, hepatobiliary, pancreatic and, in particular, colorectal neoplasms. We are reporting a case of 60-year-old female presented with carcinoma caecum along with malrotation of the gut. It is the first case report from India. We also reviewed documented cases of malrotation associated with colorectal malignancies. A large number of cases have been reported in Japan as compared to rest of the world. Malrotation in adults is probably associated with gastrointestinal malignancies. Possible causes of this association can be genetic factors or gut changes like chronic inflammation. These associations need further study to consider intestinal malrotation as premalignant lesion which may be very important in follow-up of children with malrotation.     

腹腔镜Ladd手术治疗肠旋转不良患儿中转开腹和再手术的原因分析

目的　总结腹腔镜Ladd手术在肠旋转不良患儿的中转开腹及再手术率,探讨其处理对策。方法　回顾性分析我院2014年1月至2017年1月107例接受腹腔镜Ladd手术治疗肠旋转不良患儿的临床资料及手术录像,分析术中情况、术后并发症和再次手术情况等。结果　107例患儿中男88例、女19例,男女比例为4.6：1,中位年龄为28 d（1 d～14.17岁）;新生儿（≤28 d）55例,非新生儿（＞28 d）52例。99例患儿腹腔镜Ladd手术成功完成。8例中转开腹手术者均为新生儿,其中因旋转方向难以判断中转者4例,合并环状胰腺1例,合并十二指肠隔膜1例,视野模糊1例,系膜血管损伤1例。15例患儿术后再手术,其中1例因肠梗阻于术后2周行腹腔镜探查术,术中证实为十二指肠球部溃疡穿孔;余14例均为新生儿,术中证实9例为十二指肠空肠起始端松解不彻底,2例为肠粘连导致肠梗阻,1例为十二指肠隔膜导致肠梗阻,1例为结肠狭窄导致肠梗阻,1例为关闭切口时缝合肠管导致术后肠穿孔。结论　腹腔镜Ladd手术治疗肠旋转不良安全可行,但在新生儿中开展手术仍有一定困难。完善术前检查、严格把控手术适应证、采取不同的手术策略、娴熟的腹腔镜操作技术有助于提高腹腔镜Ladd手术成功率。     

Laparoscopic surgery for repeated cecal volvulus with intestinal malrotation: A case report

This is the first report of laparoscopic surgery for an advanced‐age patient with cecal volvulus accompanied by intestinal malrotation. A 96‐year‐old woman who had previously undergone laparotomy for cecal volvulus underwent emergency laparoscopic surgery for recurrent volvulus. Because the cecum was about to rupture but not ischemic, we untwist the intestinal volvulus and fixed the cecum to the abdominal wall with a single suture. Five days after the surgery, the volvulus between the suture and the hepatic flexure of the colon recurred. We performed a second laparoscopic surgery in which we fixed the right side of the colon to the abdominal wall after diagnosing intestinal malrotation. Given its positioning, the sign of malrotation would not have been visible on preoperative CT images. As shown by this case, intestinal malrotation might lie behind the repeated cecal volvulus, and laparoscopic surgery may be a good option for volvulus with intestinal malrotation, even in cases with obstruction.     

小儿先天性肠旋转不良1例护理报告

先天性肠旋转不良,是在胎儿发育过程中,中肠(即由肠系膜上动脉供应的十二指肠至横结肠中部的一段)旋转过程中发生障碍所遗留的肠道解剖位置上的畸形。本病多发于新生儿期,幼儿期至成年人均可发病,主要表现上消化道梗阻或不全梗阻,腹胀、呕吐是本病的主要临床表现。2010年10月13日我科收治了1例先天性肠旋转不良患儿,现将其护理报道如下。