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Intestinal Malrotation Follow-up

  • Author: Denis D Bensard, MD, FACS, FAAP; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Oct 08, 2015
 

Further Outpatient Care

Long-term management of growth and nutrition

Patients with short-bowel syndrome are at high risk for failure to thrive. These infants require frequent monitoring of growth parameters during the immediate postoperative period to ensure adequate weight, length, and head circumference gains.

Patients may develop iron, folate, and vitamin B-12 deficiencies due to malabsorption depending on how much bowel is resected.

Outpatient care should be individualized, depending on each patient’s operative and postoperative course.

Development considerations

Children with prolonged hospitalization may experience developmental delays and require aggressive physical, occupational, and speech therapy.

Infants can develop poor truncal control due to prolonged periods in the supine position while hospitalized, additionally they may develop contractures in the extremities, or feeding aversion due to prolonged periods with NG tubes in place and taking nothing by mouth.

Developmental delays should be monitored in both inpatient and outpatient settings and should be intervened upon as early as possible.[39]

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Further Inpatient Care

Immediate postoperative care in patients with intestinal malrotation includes the following:

  • Intravascular volume status should be monitored postoperatively. Patients are typically hypovolemic due to operative blood loss, third spacing of fluids in the edematous bowel, and fluid and electrolyte losses from nasogastric tube decompression. Fluid resuscitation should occur with physiologic salt solution and blood products as needed.
  • Broad-spectrum antibiotics should be continued at the discretion of the surgeon.
  • NG tube decompression should be continued until bowel function returns to normal. Patients with midgut volvulus have a longer time to return of bowel function than those without volvulus; additionally, infants also experience a longer time to return of bowel function than do older children.

Nutrition in the postoperative period is as follows:

  • In the immediate postoperative period, the time to return of bowel function depends on the duration of obstruction and extent of bowel compromise. [29]
  • Most patients require total parenteral nutrition until full oral feedings can be reestablished and should have a central venous catheter placed.
  • Patients may also require intravenous infusion of amino acid solutions to achieve positive nitrogen balance.
  • Adequate nutrition is essential to ensure wound healing and protect from bacterial overgrowth.
  • Infants who are malnourished have longer recovery time.
  • Patients should receive full nutritional support with parenteral nutrition until they are able to consume at least 50% of daily caloric requirement. Parenteral nutrition can then be weaned slowly as full enteral intake is achieved.

Strategies to improve nutrition and considerations for short bowel syndrome are as follows:

  • Enteral feeding can be initiated with elemental formula. In the initial postoperative period, absorptive surface area and enzyme activity are decreased. Volume and concentration of feeds can be advanced as absorptive capacity increases.
  • Infants who undergo extensive small bowel resection are at risk of developing short bowel syndrome. These infants may require long-term parenteral nutrition until the remaining bowel is able to adapt and undergo compensatory growth. In these children, feeding should be initiated with small amounts of enteral nutrition to encourage adaptation of the bowel and provide nutrition for the mucosa. Gastrostomy tube placement may be helpful in this situation and should be assessed on a case-by-case basis. [29]
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Transfer

All children suspected of having malrotation with or without midgut volvulus should be transferred to a facility with pediatric surgical support. Furthermore, any child with bilious emesis is assumed to have a surgical problem until proven otherwise.

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Complications

Complications include the following:

  • Short-bowel syndrome: Short-bowel syndrome is the most common complication of midgut volvulus. These patients have longer delays to recovery of bowel motility and function. They are at high risk for malabsorption and can require long-term parenteral nutrition. Furthermore, these patients have more complications from treatment and longer hospital stays than patients with malrotation without volvulus.
  • Infection: Wound infections and sepsis can occur in the immediate postoperative period, requiring extended treatment with intravenous antibiotics. Additionally, central venous catheters have the potential to become infected causing bacteremia and/or sepsis
  • Surgical complications: Postoperative and surgical complications are more likely to occur in those patients with acute symptoms than those with chronic symptoms. [14] One review reported an overall complication rate of 8.7% (14 or 161) following Ladd procedure. [40] Complications reported include adhesive small bowel obstruction in 6% with 5 requiring reoperation (3%), and 1 patient developed recurrent volvulus (1%). A second review showed comparable rates of recurrent volvulus (2%, 1 of 57) and reoperation for adhesive small bowel obstruction (2%, 1 of 57). [41] Other series have reported lower rates of recurrent volvulus, 0.4% in one series of 441 patients, and 0.6% in a series of 159 patients who underwent Ladd procedure. [29]
  • Persistent GI symptoms: In the same series of 57 patients, 13 had persistent (>6 mo) GI symptoms, including constipation (6), intractable diarrhea (1), abdominal pain (2), vomiting (3), and feeding difficulties (1) following Ladd procedure. [41]
  • Mortality: Death occurs due to peritonitis, late nutritional complications, or catheter-related sepsis. Rates are increased among children younger than one year. Following Ladd procedure, mortality rates reported in the literature are as low as 2%. [40] However, if more than 75% of the bowel is necrotic, mortality is as high as 65%. [29]
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Prognosis

In general, older children do better than infants. The presence of midgut volvulus prolongs hospitalization, and prognosis is based on how much bowel is preserved. Because of the morbidity involved with midgut volvulus, immediate referral for pediatric surgical care can improve outcome more than any other medical intervention.

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Contributor Information and Disclosures
Author

Denis D Bensard, MD, FACS, FAAP Director of Pediatric Surgery and Trauma, Attending Surgeon in Adult and Pediatric Acute Care Surgery, Attending Surgeon in Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University of Colorado School of Medicine; Associate Program Director, General Surgery Residency, Attending Surgeon, Children's Hospital Colorado

Denis D Bensard, MD, FACS, FAAP is a member of the following medical societies: American Association for the Surgery of Trauma, Alpha Omega Alpha, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of University Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Shannon N Acker, MD Resident Physician, Department of Surgery, University of Colorado School of Medicine

Disclosure: Nothing to disclose.

Ann M Kulungowski, MD Assistant Professor of Pediatric Surgery, University of Colorado School of Medicine

Ann M Kulungowski, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David A Piccoli, MD Chief of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia; Professor, University of Pennsylvania School of Medicine

David A Piccoli, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Jeffrey J Du Bois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Robyn Hatley, MD Professor, Departments of Surgery and Pediatrics, Medical College of Georgia

Robyn Hatley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, and American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Anjali Parish, MD Assistant Professor of Pediatrics, Department of Neonatology, Medical College of Georgia

Anjali Parish, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

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Normal rotation of the intestines during development. The superior mesenteric artery (SMA) is the axis. The duodenojejunal loop (red arrow) begins superior to the SMA, and the cecocolic loop (green arrow) begins inferior to the SMA.
In this upper GI series with abnormal results, the duodenum does not cross the midline, and the small bowel is present only in the right side of the abdomen.
These 2 lower GI series show the cecum (arrows) in the right upper quadrant, indicative of malrotation.
This patient had malrotation with midgut volvulus. The gut is darkened in color because of ischemia.
 
 
 
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