Page 28 - 68 stomac-duodenum-&-small-intestine59-65_opt

Intestinal Malrotation and Midgut Volvulus 395

Figure 65.2: UGI depicting malrotation with all of the small bowel on the right Figure 65.3: Severe small bowel ischaemia due to volvulus.
side of the abdomen.

Complicated cases with significant bowel ischaemia still demand
Ultrasound an open approach.
Ultrasound is not the preferred imaging modality for malrotation, but The occurrence of an entire midgut strangulation and gangrene
it may be useful for some physicians with limited imaging modalities. should be considered a disaster that must be prevented, especially in
Ultrasound can be used to evaluate other abdominal abnormalities resource-poor settings where total parenteral nutrition (TPN) is neither
and may be used to visualise the position of the mesenteric vessels. available nor affordable (Figure 65.3). If widespread ischaemia of
Normally, the superior mesenteric vein is to the right of the artery. In the midgut is observed at laparotomy, limited bowel resection and a
malrotation, the vein is frequently on the left, or it may rotate complete- second-look exploration 48 to 72 hours later to confirm viability of the
ly around the artery. These findings are neither sensitive nor specific for remaining bowel are advised.
malrotation or volvulus, and should be further evaluated with additional
diagnostic imaging studies, typically a UGI. Postoperative Complications
In resource-poor settings in most developing parts of Africa, where Postoperative complications are similar to other surgical procedures
diagnostic facilities are limited or unavailable, it is safer to assume and include infection and ileus. Patients with malrotation have been
and handle all cases of bilious vomiting in a neonate as a potential known to have postoperative intestinal dysmotility (pseudo-obstruc-
malrotation syndrome with midgut volvulus. Such babies should be tion) that may delay return of the bowel function and contribute to
vigorously resuscitated and explored to avert the catastrophe of an entire their postoperative ileus. Normalisation of gut function occurs slowly
midgut strangulation and gangrene, leading to short bowel syndrome. in some children. Some reports in the literature suggest that there is an
Management underlying functional abnormality of gut innervation associated with or
15,16
as a consequence of malrotation.
Preoperative Management If the patient had bowel necrosis and required a resection,
Preoperative management is focused on stabilising the patient and depending the length of residual viable bowel, the patient may have
preparing for prompt surgery. The patient should be resuscitated with short bowel syndrome. This condition can be quite difficult to handle,
isotonic fluid (lactated Ringer’s or normal saline) with an intravenous and typically requires parenteral nutrition for at least the short term,
(IV) fluid bolus of 20 ml/kg, then kept on isotonic maintenance fluids, and potentially long term.
nothing by mouth (NPO), and nasogastric tube (NGT) decompression Patients may also have strictures, either from their resection with
until surgery. The patient’s urine output should be monitored; fluid anastomosis, or potentially from areas of ischaemia that did not require
resuscitation may depend on urine output or haemodynamics. resection. These patients may not require additional surgeries, or they
Operative Management and Technique may require subsequent bowel resection of the stricture and/or revision
Ladd’s procedure, first described in 1936, corrects the fundamental of the strictured anastomosis.
abnormality associated with malrotation and volvulus. The procedure Prognosis and Outcome
consists of laparotomy with the following steps: 13,14 Survival of children with malrotation and volvulus is high (>80%);
1. The bowel is eviscerated and the entire bowel and mesenteric root however, despite prompt diagnosis and surgery, a significant minority of
are inspected. patients still die or suffer substantial morbidity due to loss of intestines.
2. The midgut volvulus, if one exists, is derotated in a Factors associated with an increased mortality include:
counterclockwise direction. • younger age (especially less than 30 days old); 17
3. Ladd’s bands are lysed and the duodenum is straightened. • other clinical abnormalities; and
4. An appendectomy is performed. • bowel necrosis. 4,17
5. The bowel is returned into the abdominal cavity with the caecum in
the left lower quadrant. 13,14
A laparoscopic approach may be feasible in older patients, but
availability and technical comfort with this operation may be less
than optimal.