Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

Pseudo-Bartter Syndrome as an Atypical Presentation of Intestinal Malrotation: A Case Report

Intestinal malrotation is a congenital intestinal rotation anomaly and can present with various symptoms. Electrolyte disorders are very common in childhood. Pseudo-Bartter syndrome (PBS) is one of the conditions that causes electrolyte disorders and can be seen due to intestinal malrotation in children.A 3.5-month-old boy who was diagnosed as having malrotation is reported. The patient had PBS because of non-bilious vomiting. We could find only two reports on PBS related to malrotation. It is emphasized that intestinal malrotation should be considered in patients presenting with gastrointestinal symptoms such as vomiting, abdominal pain, and also PBS.

355 Incomplete Intestinal Rotation with Appendicular Abscess Causing Diagnostic Dilemma in An Adult Patient

Intestinal malrotation presents as an emergency in the neonate and within the first year of life. Incomplete intestinal rotation may remain asymptomatic and undiagnosed. Adult patients are usually diagnosed incidentally while being investigated for nonspecific abdominal symptoms. We report a case of a 43-year-old female who presented with a 10-day history of paraumbilical abdominal pain. Computed tomography demonstrated features of incomplete intestinal rotation and a centrally located inflammatory mass related to the appendix. She underwent a laparotomy and appendectomy. Upon a brief literature review of similar cases, there seems to be a conflict of views regarding the management of incidentally diagnosed adult incomplete intestinal rotation.

La malrotazione intestinale: cosa deve sapere il pediatra

Intestinal malrotation includes anomalies of intestinal rotation and fixation occurred during embryogenesis. It may present with acute or chronic-intermittent symptoms or remain asymptomatic. There are several methods to identify a defect of intestinal rotation, however an upper gastrointestinal series remains the method of choice in non-acute cases. Surgical correction is performed by open laparotomy, while the laparoscopic approach is reserved only to selected cases. This article suggests an evaluation of children with suspected intestinal malrotation and gives information about its management and complications to paediatricians.

Midgut development in rat embryos using microcomputed tomography

The development of the mammalian gut was first described more than a century ago. Since then, it has been believed that a series of highly orchestrated developmental processes occur before the intestine achieves its final formation. The key steps include the formation of the umbilicus, the so-called “physiological herniation” of the midgut into the umbilical cord, an intestinal “rotation”, and the “return of the gut” into the abdominal cavity. However, this sequence of events is predominantly based on histological sections of dissected embryos, a 2D technique with methodological limitations. For a better understanding of spatial relationships in the embryo, we utilized microcomputed tomography (µCT), a nondestructive 3D imaging method. Here, we show the detailed processes and mechanisms of intestinal development in rat embryos, including the development of the umbilicus, the formation of loops inside the umbilical coelom, and the subsequent shift of these loops into the abdominal cavity. Our 3D datasets of developing intestines will substantially advance the understanding of normal mammalian midgut embryology and offer new possibilities to reveal unknown mechanisms in the pathogenesis of congenital disorders.

A RARE CASE OF MIDGUT MALROTATION WITH VOLVULUS PRESENTING AS ACUTE BOWEL OBSTRUCTION IN ADOLESCENCE

Midgut malrotation is a congenital anomaly in the embryological development of the foetal intestinal rotation. It has been estimated that it affects approximately 1 in 500 live births . However, the true incidence is difficult to determine as a substantial number of cases will go undetected throughout life. The vast majority of the complications associated with midgut malrotation present in the first month of life and 60-85% of cases are diagnosed in this age group . It is reported that more than 90% of patients will present by the time of their first birthday . Adult midgut malrotation is very rare and its incidence has been reported to be between 0.0001% and 0.19% . Most adult diagnoses of midgut malrotation are made in asymptomatic patients; either on imaging investigations for unrelated conditions or at operations for other pathology. This scenario of incidental diagnosis is becoming increasingly common, particularly with improvements, and increased use, of diagnostic imaging techniques in modern practice. However, there are a small proportion of affected adults who may present with acute or chronic symptoms of intestinal obstruction or intermittent and recurrent abdominal pain. The true diagnosis in this age group is fraught with immense difficulty, especially because the typical presentation is with non-specific symptoms and the fact that in adults, Surgeons usually have low index of suspicion and may not consider the diagnosis a possibility in the initial evaluation of adult patients with abdominal pain.

Malrotation in Congenital Diaphragmatic Hernia: Is It Really a Problem?

Introduction Congenital diaphragmatic hernia (CDH) has been associated with other congenital malformations, such as intestinal rotation abnormalities. However, there is no standard evaluation and treatment of intestinal rotation during initial CDH repair. This study evaluates intestinal malrotation in CDH patients. Materials and Methods All patients with a CDH treated in a high-volume center between 2000 and 2015 were retrospectively evaluated. Demographics, gastrointestinal characteristics, surgical treatment, and abdominal outcomes (acute surgery, small bowel obstruction, and volvulus) were described. Results A total of 197 CDH patients were surgically repaired. In 76 (39%) patients, a malrotation was described at initial CDH repair, in 39 (20%) patients, a normal rotation, but 82 patients (42%) had no report on intestinal rotation. During follow-up (range: 2–16 years), 12 additional malrotations were diagnosed, leading to a prevalence of at least 45% (n = 88). These were mostly diagnosed due to acute small bowel obstruction, of which three had a volvulus. Of the 12 later diagnosed malrotations, 58% required acute surgery, compared to 3% of the 76 initially diagnosed patients (p < 0.001). Conclusion Malrotation is associated with CDH, with a prevalence of at least 45% and in 21% a normal intestinal rotation. “Missed” malrotations have a higher risk on need for acute surgery later in life.