Recurrent midgut volvulus in an adult patient — The case for pexy? A case report and review of the literature

Ferreira, Margarida; Simões, Joana; Folgado, António; Carlos, Sandra; Carvalho, Nuno; Santos, F; Costa, Paulo

doi:10.1016/j.ijscr.2019.11.037

Cited by 14 publications

(15 citation statements)

References 36 publications

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“…1 Of utmost importance, have been the surgical controversies concerning restitution of the mesenteric-attachments and management of the asymptomatic patients. [15][16][17][18][19][20]36 This study and other recently published data emphasized the clinicopathologic diversity of the syndrome with subtle and often overlooked symptoms in a considerable number of patients. [13][14][15][16][17][18][19][20][21][22][23][24]65,66 With increased awareness and frequent use of dedicated imaging studies, it is anticipated that there will be less misdiagnosis with increased recognition of GM as a clinical syndrome particularly in adults.…”

Section: Discussionsupporting

confidence: 68%

Five Hundred Patients With Gut Malrotation

et al. 2021

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Objectives: Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established. Methods: Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery “Kareem's procedure” was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients. Results: The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening ( P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly ( P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy ( P < 0.0001) and daily activities ( P < 0.0001). Conclusions: Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

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Section: Discussionsupporting

confidence: 68%

Five Hundred Patients With Gut Malrotation

et al. 2021

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“…In fact, although surgery is sometimes necessary, it also should be pursued cautiously. Compared to infants and children, adult patients are more likely to have major postoperative complications and have a higher reoperation rate [ 5 , 34 ]. In addition, some patients with intestinal necrosis will undergo partial small bowel resection.…”

Section: Discussionmentioning

confidence: 99%

CT facilitates improved diagnosis of adult intestinal malrotation: a 7-year retrospective study based on 332 cases

et al. 2021

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Objective To classify adult intestinal malrotation by CT. Methods This retrospective study enrolled adults diagnosed with intestinal malrotation who underwent abdominal CT at our institution between June 1, 2013, and August 30, 2020. All patients’ clinical information was recorded. Patients were divided into groups undergoing surgical and conservative management. The duodenum (nonrotation, partial rotation, and malrotation), jejunum, cecum, and the superior mesenteric artery/superior mesenteric vein relationship were reviewed on the CT images of each patient, and classification criteria developed based on the first three items. For each patient, each item was assessed separately by three radiologists. Consensus was required from at least two of them. Results A total of 332 eligible patients (218 men and 114 women; mean age 51.0 ± 15.3 years) were ultimately included and classified into ten types of malrotation. Duodenal partial rotation was present in most (73.2%, 243/332) with only 25% (83/332) demonstrating nonrotation. The jejunum was located in the right abdomen in 98.2% (326/332) of cases, and an ectopic cecum was found in only 12% (40/332, 29 cases with a left cecum, 7 pelvic, and 4 at midline). Asymptomatic patients comprised 56.6% (188/332) of cases, much higher than that in previous studies (17%, n = 82, p < .001), comprised mainly of patients with duodenal partial rotation (80.3%, 151/188). In 91 patients with detailed clinical data available (12 managed surgically and 79 conservatively), a significant difference in malrotation CT categorization was identified (p = .016). Conclusions CT enables greater detection of asymptomatic intestinal malrotation, enabling classification into multiple potentially clinically relevant subtypes.

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“…Midgut volvulus in adults is rare, with only about 120 case reports and an additional 200 patients in case series reported in the literature as of 2020 [ 1 ]. Previous case reports have reported recurrent midgut volvulus in patients with a history of childhood Ladd’s procedure [ 1 ], or an isolated incident of volvulus in elderly patients with no predisposing factors [ 2 ]. Cases in the elderly were managed with simple untwisting of the mesentery [ 2 , 3 ].…”

Section: Discussionmentioning

confidence: 99%

Recurrent midgut volvulus in an 83-year-old female

Kang

Larson

Barker

et al. 2021

Journal of Surgical Case Reports

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We present a rare case of recurrent primary midgut volvulus in an elderly female with an interesting intraoperative finding of an abnormally elongated small bowel mesentery. This patient presented with symptoms of obstruction, including nausea, vomiting and obstipation, similar to previous episodes of volvulus for which she underwent exploratory laparotomies and reduction of the volvulus. We describe a novel use for enteropexy in which we effectively shortened the small bowel mesentery in an effort to eliminate the source of recurrent volvulus. The patient’s post-operative course was complicated by prolonged ileus requiring total parenteral nutrition. However, she had not developed signs or symptoms of bowel ischemia or recurrent volvulus at the time of this writing. Our findings suggest that enteropexy is an effective technique for preventing recurrent midgut volvulus primarily caused by abnormally elongated mesentery.

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Recurrent midgut volvulus in an adult patient — The case for pexy? A case report and review of the literature

Cited by 14 publications

References 36 publications

Five Hundred Patients With Gut Malrotation

Five Hundred Patients With Gut Malrotation

CT facilitates improved diagnosis of adult intestinal malrotation: a 7-year retrospective study based on 332 cases

Recurrent midgut volvulus in an 83-year-old female

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