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Management of catastrophic neonatal midgut volvulus with a silo and second-look laparotomy.

The case of a neonate with midgut volvulus and severe intestinal ischemia extending from the ligament of Treitz to the midtransverse colon is presented. Management consisted of abdominal silo application at the initial exploration to obviate the adverse physiological consequences of increased intraabdominal pressure from reperfusion edema of the intestine. The majority of the intestine was salvaged, and a short segment of ileum was resected. This method of treatment resulted in optimal ventilatory status, renal function, and cardiac performance. The advantages of temporary prosthetic wound coverage in selected cases of midgut volvulus include greater physiologic stability through the avoidance of "intraabdominal hypertension" and the ability to monitor the status of the intestine at the bedside.

Duodenal Obstruction↗

Long-term complications following intestinal malrotation and the Ladd's procedure: a 15 year review.

BACKGROUND: It is accepted that children with volvulus require urgent surgery. However the long term sequelae and late complications of its surgical therapy are less well understood. We hypothesised that the surgical corrected intestinal malrotation have significant long term impact on the patients quality of life. METHODS: Forty-six children with intestinal malrotation were operated on at a tertiary referral centre over a fifteen year period. Their charts were retrospectively reviewed and the patients were contacted. RESULTS: The study revealed two distinct groups, those without complications 25 (54%) and those without 21 (46%). In the acute post operative period four (9%) patients had on going feeding difficulties and one (2%) developed chronic abdominal pain. However 12 (26%) required readmission within the first six months after the initial operation. Eleven (24%) patients were readmitted with acute bowel obstruction. Six (13%) patients required multiple admissions due to small bowel obstruction and six (13%) patients underwent further surgery for adhesion related obstruction. There were four (9%) deaths in the study group, three due to other medical conditions and one following small bowel obstruction. There was zero mortality immediately after the primary operation. There was no significant difference in the initial presentation, age and operative findings in those requiring further surgery and those who did not. CONCLUSIONS: We demonstrated that there is a significant long-term morbidity associated with intestinal malrotation even after corrective surgery. Detailed education about the potential for small bowel obstruction must be given to the parents of these children.

Adolescent↗

[Retractile mesenteritis after resection of Meckel's diverticulum].

HISTORY AND ADMISSION FINDINGS: A 22-year-old man who had never been seriously ill previously was admitted because of epigastric pain and vomiting of bile. INVESTIGATIONS: He had slight pain on pressure over the epigatric region and decreased intestinal peristaltic sounds. There was evidence of ileus of the small intestine both by ultrasound and radiologically. TREATMENT AND COURSE: As the patient's condition deteriorated on conservative treatment, an exploratory laparotomy was performed. It revealed an invaginated Meckel's diverticulum, Ileus of the small intestine recurred postoperatively, requiring relaparotomy. A glued-together volvulus of the small intestine had to be resected, even though there was no sign of an anastomotic leak. But there was no postoperative improvement. A third operation revealed a clearly shortened and 3 cm-thick mesentery which showed a stage III retractile mesenteritis. Histological re-examination of the specimens resected at the previous operations revealed stage I and II retractile mesenteritis. The patient's condition slowly improved on high doses of corticosteroids and he ultimately became symptom-free. CONCLUSIONS: Retractile mesenteritis is a very rare benign disease of the mesentery, almost always causing abdominal pain and diagnosed histologically by exploratory laparotomy. Administration of corticosteroids is the treatment of choice.

Adult↗

Cecal bascule: an overlooked diagnosis in the elderly.

This elderly male with a long history of alcohol abuse presented with an acute pleural trauma and hemopneumothorax, which may have served as the precipitating medical illness for cecal volvulus. He subsequently developed bacterial peritonitis as a complication of his bowel obstruction. It is probable that his pleural cavity was seeded hematogenously via a bacteremia from his peritonitis, thus accounting for the empyema with species typical of bowel flora. Cecal bascule is a type of cecal volvulus that causes intestinal obstruction. Diagnosis is difficult, but a delay in recognition may result in intestinal ischemia, perforation, sepsis, and even death. Cecal ischemia or gangrene cannot always be determined based on physical examination or laboratory findings. Plain films of the abdomen may be helpful, and barium enema has been advocated by some authors. However, laparotomy is often necessary for definitive diagnosis and therapy. While cecal volvulus has not been reported to occur frequently in the elderly, the relatively common occurrence of anatomic predisposition in addition to the widespread use of respirators and the increasing age and number of medical illnesses of our population make it possible that cecal volvulus will be seen with increasing frequency in the future.

Aged↗

Malrotation with gastric volvulus, midgut volvulus, and pancreatitis.

A 2-year-old child with intestinal malrotation had simultaneous gastric volvulus, midgut volvulus, acute pancreatitis, and gastric perforation, followed postoperatively by a temporary period of both lactosuria and sucrosuria. The gastric volvulus and midgut volvulus resulted in both proximal and distal obstruction of the duodenum, reproducing clinically a previously reported experimental model designed to produce pancreatitis. Operative reduction of the midgut volvulus and the gastric volvulus and repair of the gastric perforation was accomplished. The child has had normal growth and development during the ensuing nine years.

Child, Preschool↗

Surgical treatment of midgut nonrotation in the adult patient.

For a period of four years, five adult patients with nonrotation of the intestine and midgut volvulus have been treated. Two distinct clinical presentations were encountered. The chronic presentation is that of colicky abdominal pain, often present for many years, which is corrected by surgical intervention. The acute presentation with strangulation of the intestine may occur without pre-existing symptoms. Knowledge of this entity and a high index of suspicion are necessary for the diagnosis because massive gangrene of the intestine may result from a delay in treatment. Prophylactic surgical treatment in the asymptomatic patient is recommended to prevent this catastrophic occurrence.

Abdomen↗

Intestinal malrotation diagnosed by cholescintigraphy.

Malrotation of the gut is a congenital abnormality in which the primitive intestinal loop fails to undergo rotation to its normal adult position. Rotation of the gut may become arrested at any stage, producing abnormal locations of the intestines within the abdomen. Malrotation may cause intestinal obstruction or volvulus or may remain asymptomatic. The case presented here illustrates asymptomatic malrotation of the gut, first detected by cholescintigraphy.

Aged↗

Primary small gut volvulus in adult presenting with hematemesis.

Small gut volvulus is rare in adults and usually presents with acute intestinal obstruction. We report a 25-year-old man with primary small gut volvulus who presented with hematemesis. The gangrenous gut was resected at laparotomy. He is well 3 months later.

Abdomen, Acute↗

[Effect of obstructive malformations on the gastrointestinal tract on bilirubin levels in newborn infants].

The authors have reviewed their cases of neonatal obstructive malformations of the intestinal tract and analyzed the incidence of association with indirect hyperbilirubinemia. 39 patients in four years are considered. In 23 of them there is a bilirubin level greater than 5 mg/100 ml. A great number of high bilirubin levels (greater than 15 mg/100 ml) is associated with volvulus, malrotations and intestinal atresias. Bilirubin levels between 11 and 15 mg/100 ml are often connected with meconium ileus while ano-rectal atresias have a low bilirubin level (less than 5 mg/100 ml). The reported data allow to conclude that the jaundice is an early, but unfortunately, not specific symptom of congenital intestinal obstruction. The entero-hepatic circulation seems to be an important cause of the neonatal hyperbilirubinemia.

Anal Canal↗

Comparison of late results in patients with corrected intestinal malrotation with and without fixation of the mesentery.

Between 1940 and 1975, 86 patients with malrotation of the intestine leading to intestinal obstruction or volvulus were treated at the University Children's Hospital of Zürich. All case histories and radiograms have been examined and a questionnaire has been sent to all surviving patients. Forty-four of them were reexamined personally 3 to 37 yr later. The study was undertaken to find out whether at the time of correction of intestinal malrotation simultaneous additional fixation of the mesentery had any value. Six of the 86 patients were successfully treated nonoperatively and 3 died before surgery of other severe malformations. Of the remaining 77 children who underwent surgery, additional fixation was done in 28 of the earlier cases, but not done in 49 of the later cases. The percentage of early survivors was 85.7% in the group with intestinal fixation and 83.7% in the group without fixation. The number of reoperations was slightly lower in the group without fixation (10.4%) when compared to the group with fixation (16.6%). 25% of the children with intestinal fixation and 21% of the children without fixation had occasionally slight abdominal symptoms at a later time. These results demonstrate that intestinal fixation neither increased the number of early survivors nor reduced the number of reoperations, nor the percentage of children with abdominal complaints. It was therefore concluded that additional fixation after correction of intestinal malrotations was of no benefit and unnecessary.

Adolescent↗

The etiologic role of intrauterine volvulus and intussusception in jejunoileal atresia.

PURPOSE: Although intussusception has been reported as quite a rare cause of jejunoileal atresia (JIA), pediatric surgeons have noted the frequent presence of intussusception as well as volvulus at surgery. The aim of this study was to investigate the contribution of intrauterine intussusception and volvulus to the development of JIA. METHODS: In 48 newborns (24 boys and 24 girls) treated for JIA at our hospital between 1978 and 2004, the operative and pathologic findings were reviewed. RESULTS: Intussusception was responsible for gap and cord type atresia in 12 cases (25%). The cord showed an atrophic intestinal lumen in 2 cases. Volvulus was observed in 13 cases. Volvulus and intussusception were simultaneously noted in 1 case. This suggested that intussusception was the cause of the atresia, whereas volvulus was a secondary event. Neither intussusception nor volvulus was observed in high jejunal, apple peel, or multiple atresia. CONCLUSIONS: Intrauterine volvulus and intussusception were commonly observed in single mid- and low JIA. Thus, intrauterine intussusception may be a common cause of gap and cord type JIA. Volvulus may not only cause JIA but also result from anatomic changes after the development of JIA in some cases.

Female↗

Volvulus of the splenic flexure of the colon in a child.

A case of acute intestinal obstruction due to volvulus of the splenic flexure of the colon in an 11 year old girl is reported. This is believed to be the first reported case in the paediatric age group. Simple derotation and fixation of the splenic flexure in the normal position was carried out with a successful outcome.

Child↗

Prolonged parenteral nutrition after neonatal gastrointestinal surgery. A Danish experience.

INTRODUCTION: Long-term treatment with parenteral nutrition (PN) may be essential for survival in infants after neonatal gastrointestinal surgery. It seemed well indicated in a population-based study to estimate the need for long-term PN and to characterize the infants that received TPN with regard to diagnosis and clinical course. METHODOLOGY: This study reviews the clinical course of infants with gastrointestinal disease (gastroschisis, intestinal atresia, omphalocele, volvulus, Hirschsprung's disease and necrotizing enterocolitis) with a prolonged need for parenteral nutrition in the Western part of Denmark over a period of 11 1/2 years. RESULTS: A total of 21 patients with need for PN for 55 days or more due to gastrointestinal disease were registered with a cumulative hospital stay of 4462 days. The study showed a low incidence of long-term PN due to gastro-intestinal surgical illness with an incidence of approx 6.1 per 10(5) births per year. Gastroschisis and intestinal atresia were the most common primary diagnoses. Two groups of patients were identified: 1) six infants with short gut syndrome caused by major resections or atresia of the small intestine (less than 50 cm intestine) and 2) a larger group (n = 15) with no or only minor resection of the small bowel. The former group had a significantly longer hospital stay and a longer need for PN. The incidence of short bowel syndrome including six infants was 1.7 per 10(5) births per year. CONCLUSIONS: Prolonged need for PN in infants operated for gastrointestinal disease was registered at a low frequency in the Western part of Denmark, most frequently caused by gastroschisis and intestinal atresia. The clinical course was characterized by repetitive problems of catheter replacements and septic episodes. The mortality due to conditions related to the gastrointestinal disease was 14% (3/21).

Digestive System Surgical Procedures↗

Factors affecting prognosis in patients with short bowel syndrome.

Aim of the study is to analyse physiopathological implications of massive intestinal resection and factors affecting prognosis in patients with short bowel syndrome. Twenty massive intestinal resections were performed. The causes of bowel resection were: intestinal infarction (11 cases), Crohn's disease (5 cases), small bowel volvulus (4 cases). All intestinal resections were more than 50-60% of the intestinal length. In eighteen patients intestinal anastomosis was performed immediately. In all the patients postoperative therapy with parenteral nutrition (PN) was performed. The operative morbidity and thirty-day mortality were respectively 30% (6 cases) and 35% (7 cases). The diarrhea was the dominant symptom. The average weight was 20% lower compared to the initial weight. The length of residual small bowel and type of anastomosis strongly affect survival of patients underwent massive intestinal resections. Parenteral nutrition (PN) has great importance in postoperative treatment. A useful treatment, in severe short bowel syndrome, can be small bowel transplantation.

Adult↗

Peritoneal dialysis in neonates after major abdominal surgery.

Three newborn babies with acute renal failure were started on peritoneal dialysis 3, 4 and 3 days after abdominal surgery for intestinal perforation, intestinal malrotation with volvulus and hepatic laceration, respectively. Peritoneal access was achieved by Trocath catheters in the first two and via a Jackson-Pratt peritoneal drain inserted during surgery in the third baby. Two babies survived after dialysis for 9 and 6 days. The third baby was dialysed for 16 days, had partial recovery in renal function and died of multisystem failure at the age of 35 days. Peritoneal dialysis is possible in neonates with recent major abdominal surgery. Occasionally, a peritoneal drain inserted during surgery may provide an easy access for the procedure.

Acute Kidney Injury↗