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Prophylactic versus symptomatic Ladd procedures for pediatric malrotation
Sarah E Covey1, Luke R Putnam2, Kathryn T Anderson2
1Department of Pediatric Surgery, Center for Surgical Trials and Evidence-Based Practice, Houston, Texas.
Insights
Prophylactic Ladd procedures in infants with intestinal malrotation may reduce reoperations and complications compared to symptomatic treatment. Further prospective studies are needed to confirm benefits for asymptomatic patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Outcomes
Background:
- Intestinal malrotation can lead to life-threatening volvulus, necrosis, and sepsis.
- The Ladd procedure is the standard treatment for symptomatic malrotation.
- The necessity and timing of intervention for asymptomatic infants remain debated.
Purpose of the Study:
- To evaluate the outcomes of prophylactic Ladd procedures in asymptomatic infants with intestinal malrotation.
- To compare complication rates and recovery times between prophylactic and symptomatic Ladd procedures.
Main Methods:
- Retrospective review of pediatric patients undergoing the Ladd procedure between 2011-2014.
- Identification of prophylactic Ladd procedures performed before symptom onset.
- Statistical analysis using student t test, Mann-Whitney U, and chi-squared tests.
Main Results:
- 42 patients underwent the Ladd procedure (19 prophylactic, 23 symptomatic).
- No prophylactic Ladd procedure patients required reoperation, versus 26% of symptomatic patients (P=0.02).
- Symptomatic patients had higher rates of volvulus (39%) and necrosis (4.3%) at surgery.
Conclusions:
- Prophylactic Ladd procedures may be beneficial in infants with known malrotation, potentially reducing postoperative complications.
- Symptomatic patients, despite being sicker, experienced higher complication rates.
- A larger, prospective study is warranted to confirm the effectiveness of prophylactic Ladd procedures.
Background:
Intestinal malrotation can lead to volvulus resulting in necrosis, sepsis, and death. For symptomatic patients, treatment includes the Ladd procedure. However, debate remains regarding the timing and need for intervention for asymptomatic infants. We evaluated our experience with Ladd procedures including a clinical practice of prophylactic surgery for asymptomatic patients.
Materials And Methods:
A retrospective review of pediatric patients undergoing the Ladd procedure was performed. Prophylactic Ladd procedures were identified as those occurring before any malrotation-related symptoms. Results were analyzed with student t test, Mann-Whitney U, and chi-squared tests.
Results:
From 2011-2014, 42 patients (prophylactic = 19, symptomatic = 23) underwent the Ladd procedure. The median age (IQR, interquartile range) of patients was 9.6 (3.9-18) mo and 18 (2.4-52) mo for prophylactic and symptomatic patients, respectively (P = 0.38). In patients who underwent symptomatic Ladd procedures, nine (39%) had volvulus and one (4.3%) had bowel necrosis at time of surgery. No prophylactic Ladd procedure patients required reoperation, whereas six (26%) symptomatic patients required malrotation-related reoperations (P = 0.02). Median (IQR) days to full enteral feeds were 5.0 d (3.3-6.8) versus 7.4 (5.0-11; P = 0.11), whereas median days to discharge were 8.0 d (6.1-11) versus 11 d (7.5-32) until discharge (P = 0.09) for prophylactic and symptomatic patients, respectively.
Conclusions:
Although symptomatic patients represent sicker children, the postoperative complications appear to be higher. For infants with known malrotation, prophylactic operations may be beneficial and should be considered. A larger, prospective study to demonstrate effectiveness and generalizability for prophylactic Ladd procedure is warranted.
