TY - JOUR
T1 - Asymptomatic malrotation
T2 - Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review
AU - Graziano, Kathleen
AU - Islam, Saleem
AU - Dasgupta, Roshni
AU - Lopez, Monica E.
AU - Austin, Mary
AU - Chen, Li Ern
AU - Goldin, Adam
AU - Downard, Cynthia D.
AU - Renaud, Elizabeth
AU - Abdullah, Fizan
N1 - Publisher Copyright:
© 2015 Elsevier Inc. All rights reserved.
PY - 2015/10
Y1 - 2015/10
N2 - Objective Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. Methods Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. Results There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. Conclusions There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
AB - Objective Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. Methods Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. Results There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. Conclusions There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
KW - Asymptomatic malrotation
KW - Atypical malrotation
KW - Diagnosis and surgical management of asymptomatic malrotation
KW - Heterotaxy syndrome
KW - Intestinal rotation abnormalities
KW - Key words Malrotation
UR - http://www.scopus.com/inward/record.url?scp=84956805117&partnerID=8YFLogxK
U2 - 10.1016/j.jpedsurg.2015.06.019
DO - 10.1016/j.jpedsurg.2015.06.019
M3 - Review article
C2 - 26205079
AN - SCOPUS:84956805117
SN - 0022-3468
VL - 50
SP - 1783
EP - 1790
JO - Journal of Pediatric Surgery
JF - Journal of Pediatric Surgery
IS - 10
ER -