3/8/2014 Disclosures “I have nothing to disclose.” Management of Intestinal Malrotation in UCSF General Surgery Children vs. Adults Division of Pediatric Surgery Benjamin Padilla, MD Benjamin Padilla, MD Assistant Professor of Assistant Professor of Surgery Surgery March 2014 March 2014 2 Midgut volvulus: a surgeon’s Normal Rotation of the Midgut dilemma 3 4 1
3/8/2014 Normal Rotation of the Midgut Normal Rotation of the Midgut Right colon rotates over the top of SMA 2 . 1. Duodenum rotates behind SMA “The midgut mesentery is a plane” 5 6 Normal Rotation of the Midgut Normal Rotation of the Midgut AP Lateral 7 8 2
3/8/2014 Malrotation of the Midgut Malrotation of the Midgut 1. Duodenum fails to cross midline 2. Ladd’s bands form to RUQ AP Lateral 9 10 Fulcrum for Midgut Volvulus Fulcrum for Midgut Volvulus Clockwise rotation of the midgut 11 12 3
3/8/2014 Midgut Volvulus Ladd’s Procedure Lateral AP 13 14 Ladd’s Procedure Ladd’s Procedure is Effective www.elsevier.com/locate/jpedsurg Journa l of Pediatric Surgery (2011) 46, 1720–1725 1. Counterclockwise de-torsion of the midgut Assessment of recurrent abdominal symptoms after Ladd procedure: clinical and radiographic correlation ☆ , ☆ ☆ – “turn back the hands of time” David M. Biko a,b, ⁎ , S udha A. Anupindi a , S tephanie B. Hanhan a,c , hane Blinman d , R ichard I. Markowitz a T 2. Divide Ladd’s bands a Department of Radiology, The Children's Hospital of Philadelphia, Phildelphia, PA 19104, US A b Department of Radiology, National Naval Medical Center, Bethesda, MD 20889, US A c Department of Radiology, Jersey S hore University Medical Center, Neptune NJ 07753, US A d Department of General S urgery, The Children's Hospital of Philadelphia, Phildelphia, PA 19104, US A 3. Broaden the midgut mesentery • 147 patients over 10-year period • 38 (26%) post-operative complications 4. Appendectomy • 11 (7.5%) reoperation 5. Place the midgut in “non-rotated” configuration • 8 (5.4%) Adhesive SBO – Small bowel >>> Right • 1 (0.7%) Volvulus – Colon >>> Left • Laparoscopic vs Open – Cecum >>> Hypogastric midline • Similar complication rates 15 16 4
3/8/2014 Age-related Presentation Age-related Presentation Age at presentation Duration of symptoms by age Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93. Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93. 17 18 Age-related Presentation Management of “Asymptomatic” Malrotation Presenting symptoms by age • Markov decision analysis Parameters • Risk of observation: volvulus, short gut, death • Risk of operation: death Treatment recommendation • QALY gain by either operation or observation “ “ QALY gained by “ “ elective Ladd ’ ’ ’ ’ s Procedure ” ” ” ” � Children: Ladd’s procedure should be considered � Adults: The risk of midgut volvulus does not justify prophylactic Ladd’s procedure Nehra and Goldstein. Surgery. 2011 Mar;149(3):386-93. Malek and Burd. Am J Surg. 2006 Jan;191(1):45-51. 19 20 5
3/8/2014 Summary Opening February 1, 2014 • 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 21 22 6
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