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Malrotation: Age-Related Differences in Reoperation Rate
Arimatias Raitio1, Patrick A Green1, David W Fawkner-Corbett1
1Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, Merseyside, United Kingdom.
Insights
Surgery for intestinal malrotation in older children leads to a higher reoperation rate compared to infants. A duodenal bypass may be considered for chronic obstruction in older children.
Area of Science:
- Pediatric Surgery
- Gastrointestinal Surgery
- Surgical Outcomes Research
Background:
- Intestinal malrotation typically presents in neonates but is often diagnosed later in childhood or adulthood.
- Delayed diagnosis of intestinal malrotation is linked to increased morbidity.
- Surgical complexity and outcomes in older children with malrotation require further investigation.
Purpose of the Study:
- To investigate the hypothesis that surgery for intestinal malrotation in older children is associated with increased morbidity compared to infants.
- To compare emergency reoperation rates, need for bypass procedures, and mortality between infant and older children undergoing malrotation surgery.
Main Methods:
- Retrospective analysis of 131 children (infants < 1 year, older children > 1 year) with intestinal malrotation undergoing laparotomy between 2002 and 2014.
- Primary outcome: emergency reoperation rate.
- Secondary outcomes: requirement for bypass at reoperation and mortality.
Main Results:
- Older children had a significantly higher emergency reoperation rate (7/27) compared to infants (6/104).
- Bypass procedures were more frequently required in older children (4/27) than infants (2/104).
- Mortality occurred in 3 patients (2.3%), all in the infant group, with one directly related to malrotation.
Conclusions:
- Surgical management of intestinal malrotation in older children is associated with a higher risk of emergency reoperation.
- Consideration of a primary duodenal bypass procedure is recommended for older children with chronic intermittent obstruction due to malrotation, especially if the standard Ladd procedure is insufficient.
Objective:
Intestinal malrotation classically presents in the neonatal period with bilious vomiting. However, population studies suggest that up to two-thirds of these patients are diagnosed later in childhood or in adulthood. Increased morbidity in the adult population has been reported. Local experience suggested that surgery was technically more difficult in older children and led to the hypothesis that it would be associated with increased morbidity.
Methods:
A retrospective case note analysis was performed on all children presenting with intestinal malrotation to a tertiary referral center between January 2002 and November 2014. Case notes and operation records were reviewed and those who underwent laparotomy for confirmed malrotation were included. Children were grouped as infants (< 1 year) and older (> 1 year). The primary outcome was total emergency reoperation rate. Secondary outcomes were requirement for a bypass at reoperation and mortality.
Results:
A total of 131 children with malrotation were identified (104 infants, 27 older children; 78 males; age range, 0-16 years). Overall, 13 patients had emergency reoperation following initial Ladd procedure (6 infants and 7 older children). Risk for reoperation was significantly higher in older children (p = 0.005) and additionally a bypass procedure was more often required in older children than infants (4 children, 2 infants, p = 0.016). Adhesiolysis was required on four occasions and redo Ladd procedure in two; these were evenly distributed between both groups. One child was found to have distal bowel obstruction at reoperation. There were three deaths (2.3%), all in the infant group. One was directly associated with malrotation with extensive bowel necrosis. The other two died of unrelated sepsis several months later.
Conclusions:
Malrotation surgery in older children is associated with a significantly higher emergency reoperation rate. The primary duodenal bypass procedure should always be considered with longstanding chronic intermittent obstruction associated with malrotation if the simple Ladd procedure is deemed inadequate.
