Intestinal Volvulus Treatment & Management

The management of abnormalities of rotation and volvulus is well established. Surgical correction is indicated; no other treatment is available. The most important point is to recognize and address the diagnosis early before complications develop. Some authors have reported using laparoscopy to treat these conditions, but this has not become standard practice and is still being evaluated.

A surgeon should be immediately consulted when malrotation or volvulus is suspected. Any symptomatic child with peritonitis should be taken immediately for laparotomy. If peritonitis is not present, the diagnosis should be confirmed with an upper gastrointestinal (GI) contrast study, and the child should be resuscitated with intravenous (IV) fluids before surgery. However, any compromise of blood flow to the involved bowel constitutes a true surgical emergency.

Consider unexplained bilious vomiting in an otherwise healthy infant a surgical emergency; likewise, assume malrotation with midgut volvulus until proven otherwise.

Some would consider the use of prokinetics in infants inadvisable until imaging has ruled out intestinal malrotation.

In neonates who have not established oral feeding and bowel function, ruling out duodenal atresia, stenosis, or web at the time of surgery is important.

Although definitive treatment of malrotation and intestinal volvulus consists of surgical correction, there is a role for nonoperative measures. Medical care revolves around support of the patient preoperatively and postoperatively, treatment or stabilization of any coexisting conditions, and expedition of transport to the operating room (OR).

Nonoperative treatment might be appropriate for older patients that have intestinal malrotation and are truly asymptomatic. However, the patient and the family must be made aware that intestinal volvulus may occur at any time and that they must seek immediate medical attention if any GI symptoms develop.

Insertion of a nasogastric or orogastric tube begins GI decompression. This may be successful in alleviating the vomiting and discomfort associated with obstruction. Rectal tube decompression of a sigmoid volvulus can be achieved. This may be aided by endoscopic placement.

The respiratory system is supported with intubation and ventilation as needed. Prophylactic broad-spectrum antibiotics are administered and continued postoperatively if the bowel vascular supply is compromised, causing necrosis.

Fluid and electrolyte status is closely monitored, with IV fluids administered at least at maintenance levels and increased for any signs of dehydration or fluid shifts. Electrolytes are aggressively replaced. Foley catheter placement may be appropriate, especially in older children. In addition, if volvulus has not yet occurred, closely monitor for acute changes in symptoms (eg, vomiting, distention, fever, hemodynamic instability), which may show that volvulus has occurred.

Definitive treatment for sigmoid volvulus remains surgical with resection and primary anastomosis. As with most instances of bowel resection, an open approach is usually used. Most patients undergo the Ladd procedure. A laparoscopic Ladd procedure has been described with good success rates.^[15]

Once the diagnosis of volvulus has been established, urgently proceeding to operative intervention is important. Do not delay operation in a patient who is not stable. A brief period spent on supportive measures (see above) may be appropriate; however, the main goal is to reduce the volvulus as quickly as possible by means of surgical exploration.

During the operation, the midgut volvulus is reduced by untwisting the bowel in a counterclockwise fashion. The viability of the small bowel loops can then be assessed. Doppler probe or fluorescein with a Wood light may be helpful in documenting bowel viability. Necrotic bowel is resected if it is encountered.

The basis of surgical correction of malrotation is to free obstruction and to widen the base of mesenteric attachment. Several approaches were attempted with some success before Ladd first described a reliable technique in 1932. His approach placed the intestines in a prior embryologic state but accomplished the greatest stability to that point. His procedure survives, relatively unchanged, as the most widely used technique.

Incision and exposure

A transverse incision is made through the right rectus muscle in the right upper quadrant. This incision allows the greatest visualization and access to the anatomy. Upon exploration, 1 of 2 arrangements of the intestine is commonly seen.

In one arrangement, the cecum is visible in the right upper quadrant and is attached to the retroperitoneum by Ladd bands (see Pathophysiology), which cross in front of the duodenum. This is usually associated with duodenal obstruction but not with volvulus or ischemia. The peritoneal bands should be divided, and the cecum and ascending colon should be moved to the left side of the abdomen as far from the duodenum as possible.

In the other, more common arrangement, the colon is obscured by loops of small bowel. This is the pattern in patients with volvulus, with or without bowel ischemia. The intestines should be delivered from the abdomen. The surgeon is then able to observe that the entire midgut is attached by a very narrow pedicle containing the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) and little else, which may or may not be twisted at its base. Loops of small bowel may be seen coiled around the base of the mesentery.

Chylous ascites is occasionally present. This turbid fluid may appear infected but is actually sterile.

Untwisting of bowel

The intestine is rotated counterclockwise until the twist is completely relieved (see the images below). This may require up to 3 complete turns of the bowel. During correction of malrotation, thoroughly examine the bowel for signs of necrosis and cover the bowel with warm sponges to allow restoration of blood flow.

The SMA pedicle is dissected free of any constricting peritoneal attachment all the way to the pancreas to facilitate the widening of the pedicle. Ladd bands, which constrict the duodenum, are thoroughly divided with the help of a Kocher maneuver to ensure resolution of restriction. Closing or widening any defect to prevent future strangulation can repair mesocolic hernias.

Appendectomy

In the absence of cecal necrosis, most surgeons also perform an appendectomy; this prevents any subsequent confusion in diagnosing appendicitis that may arise from the abnormal position of the cecum and appendix on the left side of the abdomen.

After the previously described steps have been accomplished, the bowel is returned to the abdomen in the nonrotated position, with the proximal small bowel on the far right, the colon on the far left, and the mesentery spread out like an apron between them. The appendix is then removed. As a rule, no attempt should be made to stitch (or fixate) the bowel down to prevent it from twisting again.

Excision of necrotic bowel

Any bowel that is frankly necrotic should be conservatively excised (see the image below). A primary reanastomosis or enterostomy and mucous fistula can be performed, depending on the state of the bowel at the resection margin and the extent of the resection. If the bowel is congested and ischemic but not frankly necrotic, it may be left in situ after the volvulus is reduced. Edematous and ischemic bowel may regain function over the next few days. This may necessitate a second-look laparotomy within 24-48 hours from the initial operation.

The length of remaining jejunum and ileum should be carefully measured and documented. Focus all efforts on leaving most of the bowel intact if possible because necrosis and resection of large amounts of bowel cause long-term nutritional problems and may lead to death. When a massive resection that will leave less than 100 cm of healthy small bowel is necessary, a gastrostomy may be inserted.

If a significant length of unresected bowel is of questionable viability after the initial operation, it may be reinspected and its viability reassessed at a planned second-look operation within 24-48 hours.

In the tragic case of total midgut infarction, close the abdomen with the entire bowel intact, and provide terminal care.

Confirmation of duodenal patency

Duodenal patency must be ensured before closure. Many techniques have been used (eg, injection of air or saline), but the most successful is to use a large Fogarty embolectomy catheter or another appropriately sized balloon-tipped catheter. The catheter is inserted orogastrically or nasogastrically and advanced through the duodenum. The balloon is then inflated and retracted through the duodenum. Atresia prevents the complete passage of the catheter; stenosis or a duodenal web or diaphragm causes tension on the intestinal wall upon retraction of the catheter.

Transluminal repair of any obstruction is preferred if possible, or resection with end-to-end reanastomosis is performed.

Closure of abdomen

If the abdominal wall cannot be closed without causing abdominal compartment syndrome, a silo may be placed for temporary closure. This technique has been used with some significant success.

Edematous bowel may place excessive pressure on the diaphragm, great vessels, and kidneys, causing hemodynamic, respiratory, and renal compromise. A silo optimizes cardiorespiratory status while optimizing blood flow through the SMA. Additionally, the silo may allow a bedside second-look, thus decreasing expenses and transport, which is especially pertinent in the care of premature neonates. Surgeons must use clinical judgment in the assessment of abdominal pressures for the purpose of silo application.

Role of laparoscopy

A laparoscopic variation of the Ladd procedure, following the same principles as the open procedure, has been used in many pediatric surgical centers. Laparoscopic surgery provides the general advantage of decreased scarring and adhesions; although adhesions may create obstructive problems in 1-10% of patients, they may also provide stability to the new intestinal placement. However, good visualization of the entire bowel is vital to the accurate resection or preservation of ischemic bowel, and a laparoscopic approach impairs full examination of the intestine. For that reason, if necrosis is seen at the time of laparoscopy, the procedure should be converted to open laparotomy.

Successful laparoscopic management of malrotation has been described in a number of case reports and small series.^[16] It remains unclear, however, whether laparoscopy for the treatment of malrotation has a success rate equal to that of open surgery. Preliminary data suggest that it is equally effective.

Role of cecal or duodenal fixation

The 7% recurrence rate of volvulus after the Ladd procedure has encouraged surgeons to attempt fixation of the cecum and/or duodenum. In 1966, Bill reported successful results with fixation of the cecum in the left lower quadrant with and without duodenal fixation.^[17]

Other authors have argued that volvulus recurrence rates remain unchanged and that continued abdominal symptoms are more common after fixation; therefore, in general, cecal and duodenal fixation are not widely used today. Applications may be noted; in 1992, Ford et al used colopexy and duodenopexy only in rare cases of persistent narrow SMA pedicle despite dissection of peritoneal attachments with good results.^[11]

In 1975, Gohl and DeMeester used the less well-known Fitzgerald technique with good results in adults.^[18] This approach places the bowel in the mature anatomic position. The abdomen is entered through a midline incision. The surgeon then lyses bands and peritoneal attachments to mobilize the bowel. A new retroperitoneal bed is created in the right paravertebral gutter for the placement of the ascending colon, which is then secured laterally.

The small bowel is pulled under the base of the colonic mesentery, with fixation of the duodenum medially and a new ligament of Treitz at the duodenal exit beneath the transverse mesocolon. Historically, most authors have reported difficulty with the creation of a new ligament of Treitz of the proper tension. Fixation may also contribute to continued symptoms. For that reason, fixation is no longer recommended in the management of malrotation and volvulus.

Management of associated anomalies

Coexisting conditions may complicate clinical decisions. Stabilize congenital heart defects before the Ladd procedure in the absence of ischemic volvulus.

In the case of malrotation and Hirschsprung disease, surgery is also delayed, if possible, until a simultaneous pull-through can be accomplished. In these cases, educate patients and parents on obstructive symptoms.

In Waugh syndrome, intussusception can often be reduced with contrast enema. The Ladd procedure actually adds to hospital stay and expenses, and it appears inefficient. However, intussusception is likely to recur if the anatomic defect remains.

Abdominal wall defects may contribute to thickening and shortening of the bowel, making anatomic identification and correction difficult.

Complications of surgery

The most common postoperative complications are adhesive obstruction, short-bowel syndrome (occurring in 20% of cases), and recurrent volvulus (occurring in as many as 8%). Patients who have large portions of necrotic intestine that require resection have chronic difficulties with short-bowel syndrome. Motility disturbances develop in some children. A prolonged paralytic ileus may complicate the postoperative recovery.

Make resources available early to prevent any difficulties with long-term care. Educate the parents of these patients, as well as the patients themselves, if appropriate, to prevent difficulties resulting from complications.

Postoperative care depends on the presence of other abnormalities, which should be treated accordingly, and the presence of necrotic bowel.

After the procedure, transfer the patient to an intensive care unit (ICU) and observe for signs of deterioration or recurring volvulus. The patient should remain in the ICU at least until the second-look laparotomy and longer if indicated. Questionable bowel may either recover (sometimes slowly) or become necrotic. Use antibiotics in the presence of necrotic bowel.

Postoperatively, patients still require aggressive fluid resuscitation and IV antibiotics. IV parenteral nutrition is begun in patients who have undergone resection of a significant length of necrotic bowel. When the entire bowel appears necrotic, massive resection typically results in short-bowel syndrome and a lifetime of parenteral nutrition with its associated morbidities, most notably progressive cholestatic liver disease.

Small bowel transplant for short-bowel syndrome continues to be associated with high morbidity and mortality, although increasing experience and advances in immunosuppressive therapy continue to increase the survival rates in children. Early listing with a small bowel transplant service before the development of end-stage liver disease may result in improved outcome after transplant.

Any signs and symptoms of obstruction should be noted by physicians and family members and attended to quickly. It is important to remember that recurrent volvulus may occur even after a successful Ladd procedure (open or laparoscopic). For that reason, recurrent bilious vomiting in a patient with a history of corrected malrotation should be investigated promptly.^[7]

Dietary measures

The determination of diet postoperatively depends on the degree of bowel distress. Markedly edematous bowel may take longer to recuperate, delaying the tolerance of oral feeds. Total parenteral feeds may be necessary in the interim period. In addition, if a significant portion of the bowel is removed, and short-bowel syndrome develops, a lifetime of dietary modifications, and possibly long-term hyperalimentation supplementation, will be necessary.

However, in the absence of complicating factors, feeding can resume as soon as the bowel recovers and toleration begins. No special diet is required.

Activity restriction

No specific restrictions regarding postoperative activity are indicated. Age-appropriate activity is always encouraged as soon as tolerated after surgery, barring other restricting abnormalities.

The child with malrotation should have access to a hospital system with critical care facilities appropriate for the child’s age and an experienced staff, including a pediatrician, pediatric surgeon, and radiologist. If these resources are not available, transfer the patient to a facility that can provide them.

A pediatric surgeon should be involved early in the care of any patient suspected of having malrotation or intestinal volvulus. The surgeon, pediatrician, and an experienced radiologist should be directly involved in the performance of imaging studies. In the case of volvulus, rapid procession to the OR may be necessary, and all facilitating measures should be taken.