Midgut volvulus in an adult with congenital malrotation

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small-bowel obstruction, rarely is observed beyond the first year of life. Symptomatic patients present with either acute bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or with chronic vague abdominal pain. Chronic symptoms often can make the diagnosis difficult. By using several modalities such as barium studies, computerized tomography, angiography, and emergency laparotomy, we diagnosed midgut volvulus and partial intestinal obstruction, which occur rarely in an adult with congenital midgut malrotation.     

Laparoscopic ladd procedure for adult malrotation of the midgut with cocoon deformity: report of a case

Intestinal malrotation of the midgut is well documented in infants and children but rare in adults. Most adults with intestinal malrotation are asymptomatic, and the anomaly is found incidentally at laparotomy. Classically, the Ladd procedure via a laparotomy is the treatment of choice for patients with symptomatic malrotation. Laparoscopic Ladd procedures have been described in the pediatric literature, but little is known of its efficacy and applicability in adults. We present the case of a symptomatic adult patient found to have malrotation of the midgut with a cocoon deformity, a rare anomaly, that was treated successfully by a laparoscopic Ladd procedure, and we discuss the role of laparoscopy in this entity.     

Volvolus in an adult patient due to intestinal malrotation. Case report and review of literature

Intestinal malrotation is a rare cause of bowel obstruction in adults and it could create a perplexing situation for surgeons not familiar with this pediatric pathology. Symptomatic patients present either acutely with bowel obstruction and intestinal ischemia with a midgut or cecal volvolus, or chronically with vague abdominal pain. Several modalities can be used to describe the intestinal abnormality such as barium X-ray, computer tomography scans, angiography and sometimes also the explorative laparotomy. The authors report on a case 62 years-old women presented to Emergency Center for plurime episodies of biliar emesis and diffuse abdominal pain in the last 5 days and treated for bowel obstruction secondary to a midgut volvolus in anomaly of fetal intestinal rotation.     

Intestinal obstruction from midgut volvulus after laparoscopic cholecystectomy

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small bowel obstruction, rarely is recognized beyond the first year of life. We report a case of unrecognized congenital midgut malrotation that resulted in midgut volvulus, causing intestinal obstruction and requiring emergent reoperation after laparoscopic cholecystectomy. This unusual complication, first reported in 1994, involved a 56-year-old man and resulted in cecal infarction recognized and treated on the second postoperative day. This second case describes a less acute postoperative course, with multiple bouts of partial bowel obstruction leading to two readmissions and finally resulting in a reexploration and definitive treatment on the 19th postoperative day. Received: 16 February 1999/Accepted: 22 March 1999     

Intestinal malrotation in an adult: case report

Intestinal malrotation is a developmental anomaly of the midgut in which the normal fetal rotation of intestines around the superior mesenteric artery and their fixation in the peritoneal cavity fail. Rotational anomalies of the midgut are rare in adults. Operative intervention is required generally when they are symptomatic. While difficult to diagnose, prompt recognition and surgical treatment usually lead to a successful outcome. Intestinal malrotation is rarely asymptomatic and generally diagnosed incidentally in adults. In the present report, a case of incidental intestinal malrotation with clinical findings of small bowel obstruction is discussed with a literature review.     

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.     

Dorsal mesenteric agenesis without small bowel atresia: a rare cause of midgut volvulus in children

Agenesis of the dorsal mesentery in association with jejunal atresia is a well-recognized congenital anomaly. Only few reports exist in the English literature of children with agenesis of the dorsal mesentery without small bowel atresia. Herein, we report a child with total mesenteric agenesis presenting with midgut volvulus owing to internal herniation of the small bowel through a mesenteric defect, with normal fixation and rotation of the bowel.     

Outcomes after a Ladd procedure for intestinal malrotation with heterotaxia

Purpose

Intestinal rotation abnormalities and complex congenital heart disease associated with heterotaxia coexist. Despite the risk for midgut volvulus, performing a Ladd procedure for asymptomatic malrotation with heterotaxia remains to be controversial because the presumed risk for postoperative complications is thought to exceed the benefits of the operation. The purpose of this study was to review the incidence of complications after a Ladd procedure in asymptomatic patients with heterotaxia to guide recommendations for this patient population.

Methods

The medical records of all patients with heterotaxia who underwent a Ladd procedure for asymptomatic malrotation between 1984 and 2004 were reviewed. Type of cardiac disease, postoperative complications, and survival were recorded.

Results

Twenty-two patients (9 boys and 13 girls) with heterotaxia underwent an elective Ladd procedure after their medical stabilization or surgical correction or palliation of their cardiac anomaly. Of these patients, 19 were younger than 1 month at the time of the operation. The remaining 3 patients underwent the operation when they were between 2 and 5 months old. Three of the 22 patients (14%) developed postoperative intestinal obstruction: lysis of adhesions was performed in 1 patient; another patient required a staged bowel resection for a closed loop obstruction; and yet another patient had recurrent midgut volvulus 4 years after an incomplete initial Ladd procedure. All patients survived the initial and secondary procedures. Four deaths, all more than 1 month after the surgery, occurred as sequelae of the underlying cardiac anomaly. Length of follow-up ranged from 1 to 17 years.

Conclusions

We report on a 14% risk of postoperative bowel obstruction after an elective Ladd procedure, as compared with a small but significant incidence of midgut volvulus in patients with malrotation in the setting of complex congenital heart disease. Our results support the conclusion that an elective Ladd procedure at a time of relative cardiac stability for selected patients with heterotaxia has an acceptably low morbidity and should be considered to prevent midgut volvulus.     

Neonatal intestinal volvulus and preduodenal portal vein associated with situs ambiguus: report of a case

Situs ambiguus is a rare lateralization anomaly that is frequently associated with other malformations, including preduodenal portal vein (PDPV), intestinal malrotation, and cardiovascular anomalies. This is a case report on a newborn that was clinically diagnosed with situs ambiguus and midgut volvulus. During surgery the patient was found to have intestinal malrotation, Meckel’s diverticulum, and PDPV that was not a direct cause of duodenal obstruction. The patient was treated with Ladd’s procedure and resection of Meckel’s diverticulum. It is important to be familiar with the spectrum of situs anomalies to prevent trauma to the portal vein with serious complications during surgery.     

Intestinal malrotation with midgut volvulus presenting as acute abdomen in children: value of diagnostic and therapeutic laparoscopy

INTRODUCTION: Intestinal malrotation is a developmental anomaly of intestinal fixation and rotation caused by a disruption in the normal embryologic development of the bowel. Normal rotation takes place around the superior mesenteric artery. Incomplete rotation and midgut volvulus is the commonest type of anomaly. Intestinal obstruction is the commonest presentation in symptomatic cases. PATIENTS AND METHODS: Between 2000 and 2006, 73 children with acute abdomen underwent a diagnostic laparoscopy procedure. In this paper, we report 7 cases (9.5%) of midgut malrotation with volvulus and acute abdomen. Age range was between 7 and 12 years; there were 4 females and 3 males. They all presented with features of intestinal obstruction. A diagnosis of malrotation was established in only 1 patient, whereas the other 6 were diagnosed on laparoscopy. A laparoscopic Ladd's procedure was successfully performed for all cases. There were no postoperative complications. DISCUSSION: Intestinal malrotation occurs at a rate of 1 in 500 live births. The Ladd's procedure is the operation of choice. In 1995, the first report of laparoscopic surgery for malrotation was published. Since then, many studies were reported. Laparoscopy is a well-established diagnostic and treatment modality for this condition, even in the presence of volvulus. CONCLUSIONS: Our study shows the diagnostic value of laparoscopy in acute abdomen in children. The other advantages include less postoperative pain, a better cosmesis, especially in children, early return of bowel movement, and early discharge.     

Re-do Roux-en-Y Gastric Bypass in a Patient with Known Midgut Malrotation

A 40-year-old woman presented with small bowel obstruction caused by an internal hernia through Peterson''s defect. The patient was known to have midgut malrotation (MM) and also had laparoscopic Roux-en-Y gastric bypass for morbid obesity 6 years prior. An open revision of Roux-en-Y gastric bypass was performed as a result of ischemia of alimentary limb. She made a slow but uneventful recovery and was discharged home.MM is a rare congenital anomaly that requires the surgeon to be well aware of the unique variation in anatomy to perform a mirror image of the routine Roux-en-Y gastric bypass.At the end of this case report, we present a short literature review of published data related to MM encountered during Roux-en-Y gastric bypass.     

Preduodenal portal vein in association with midgut malrotation and duodenal web—triple anomaly?

Preduodenal portal vein (PDPV) is a rare anomaly in which the portal vein passes anterior to the duodenum rather than posteriorly. Generally asymptomatic, PDPV may rarely cause duodenal obstruction or may coexist with other anomalies. We report a neonate who presented with duodenal obstruction and was found out to have 3 coexisting anomalies, each of which can lead to duodenal obstruction independently—PDPV, midgut malrotation, and duodenal web. A duodenoduodenostomy and a Ladd procedure were done, and the child recovered uneventfully. The mechanism of obstruction, interesting metabolic aberrations observed, outcome, and relevant literature are presented.     

Adult malrotation: a case report and review of the literature

Midgut malrotation is an anomaly of fetal intestinal rotation that usually presents in the first month of life. It is rare for malrotation to present in adulthood. Symptomatic patients present either acutely with bowel obstruction and intestinal ischemia with a midgut or cecal volvulus, or chronically with vague abdominal pain. Chronic symptoms can often make the diagnosis difficult. Findings diagnostic of malrotation are described using several modalities such as barium studies, computed tomography (CT) scans, angiography, and often emergent laparotomy. Treatment remains the Ladd procedure originally described by Dr. Ladd in 1936. Complete resolution of acute obstruction or chronic abdominal pain is the result of a high index of suspicion for malrotation, appropriate diagnostic studies, and aggressive definitive surgical treatment. We present a case of malrotation in an adult who presented with chronic abdominal pain. Midgut malrotation is a congenital anomaly referring to either lack of or incomplete rotation of the fetal intestines around the axis of the superior mesenteric artery during fetal development. Most patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus. It is rare for this condition to present in adulthood. The true incidence in adults is difficult to estimate because most patients who remain are asymptomatic and their conditions are, therefore, never diagnosed. A literature review by von Flue et al cites 40 cases from 1923 to 1992. Patients who are symptomatic often present either acutely with bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or chronically with vague abdominal pain. These symptoms are caused by peritoneal bands first described by Ladd in 1932. These bands run from the cecum to the right lateral abdominal wall. We present a case of malrotation in an adult who presented with chronic abdominal pain.     

A rare presentation of midgut malrotation as an acute intestinal obstruction in an adult: Two case reports and literature review

INTRODUCTIONMidgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.PRESENTATION OF CASEWe report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.DISCUSSIONMalrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.CONCLUSIONAnomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.     

Laparoscopic surgery for appendiceal cancer with intestinal malrotation in an adult: A case report

IntroductionIntestinal malrotation is a congenital anatomical anomaly resulting from abnormal midgut rotation. Many cases occur during childhood and present with intestinal obstruction and midgut volvulus. Intestinal malrotation rarely occurs in adults and is found incidentally because it is asymptomatic. We herein report a case of intestinal malrotation, and colorectal cancer operated laparoscopically.Presentation of caseA 78-year-old man presented to our Department of Surgical Gastroenterology with fecal occult blood. There were no abnormal findings in the physical examination. Colonoscopy revealed a type 3 tumor in the cecum. Contrast-enhanced computed tomography revealed that the tumor was located in the appendix along the midline of the abdomen. The small intestine and colon occupied the right and left sides of the abdominal cavity, respectively. The diagnosis was appendiceal cancer with nonrotation-type intestinal malrotation. A laparoscopy-assisted ileocecal resection was performed. During surgery, the right-side colon was not fixed to the retroperitoneum, and the right-side colon could be extracted out of the abdominal cavity through the umbilical wound with only adhesive dissection, and mesenteric and lymph node dissection can be performed outside the body. The postoperative course was uneventful.DiscussionAppendiceal cancer with intestinal malrotation is managed with laparoscopic surgery because this method is safe and minimally invasive.ConclusionThe laparoscopic approach may be safer and less invasive than laparotomy, and extracorporeal lymph node dissection is safe and reliable for patients with intestinal malrotation.     

Incarcerated ventral (epigastric) hernia containing a strangulated Meckel's diverticulum

Summary A Meckel's diverticulum is the result of an incomplete obliteration of the omphalomesenteric, or vitelline, duct. The duct connects the midgut to the yolk sac of the developing intestinal tract and normally atrophies by the eighth to ninth week of gestation. This event fails to occur in approximately two percent of the population, resulting in the congenital anomaly named after Johann Friedrich Meckel, who first characterized this diverticulum in 1809. Our patient presented with signs and symptoms consistent with a small bowel obstruction secondary to an incarcerated hernia, and underwent emergent laparotomy. An ischemie small bowel segment with a Meckel's diverticulum was resected. Pathology revealed ectopic pancreatic tissue within the diverticulum. Meckel's diverticula have been observed among the contents of hernia sacs in various locations including the inguinal, femoral, and umbilical regions. We report a case of a Meckel's diverticulum presenting in a spontaneous ventral (epigastric) hernia.     

Rare small bowel obstruction: Right paraduodenal hernia. Case report

INTRODUCTIONParaduodenal hernia (paramesocolic hernia), a rare congenital anomaly due to a midgut malrotation during fetal development, is recognized as the most frequent internal hernias. Two variants have been described: left and right, the latter less common than the first one.PRESENTATION OF CASEWe report a right paraduodenal hernia case in a 86 years old female patient who developed an acute bowel obstruction syndrome. Final diagnosis was achieved by imaging techniques as abdomen X-ray and CT and confirmed only after surgical operation.DISCUSSIONSurgical approach was via median laparotomy, consisting in hernia reduction, replacement and stitching of the bowel in its anatomical orientation, and fixing of the posterior wall defect. At 15 months follow-up from surgical procedure the patient is asymptomatic.CONCLUSIONParaduodenal hernia is a rare pathology but its involvement in bowel obstruction syndrome should be always taken into account during diagnostic process.     

Computed tomographic diagnosis of midgut volvulus in a 5-year-old child

Malrotation with midgut volvulus requires prompt recognition and urgent treatment. We describe a 5-year-old boy who presented with malrotation and midgut volvulus in whom the diagnosis was made by computed tomography. We describe the diagnostic images and operative findings in the patient. This case highlights the importance of recognizing the inversion in orientation of the superior mesenteric vessels and “whirlpool” sign in making the diagnosis of midgut volvulus when few other clues may be present.     

Intestinal obstruction from midgut volvulus after laparoscopic appendectomy

We present the case of a 30-year-old man who developed a small bowel obstruction from an acute midgut volvulus 8 days after undergoing a laparoscopic appendectomy. There was no evidence of congenital malrotation or midgut volvulus on the initial computed tomography (CT) scan or at laparoscopy. Subsequently, a midgut volvulus developed in the absence of congenital malrotation.     

Bilious vomiting in the newborn

Bilious (dark green) vomiting in the newborn is a surgical emergency as the underlying diagnosis may be volvulus of the entire midgut secondary to malrotation. This diagnosis is time critical as, untreated, volvulus will lead to midgut necrosis, resulting in short gut syndrome or death. While a range of other diagnoses are possible, transfer to a paediatric surgical centre should be undertaken urgently so that malrotation/volvulus can be excluded or treated. This review focuses on the causes, investigation and management of proximal bowel obstruction in the neonate that present primarily with bilious vomiting.