Abstract
Aim-Background
Acute presentation in adulthood of the indolent developmental midgut malformations constitutes a diagnostic problem and emergent surgery may result to an operative surprise.
Methods
In the last five years two women (case I: 46 years, case II: 88 years) and two men (case III: 42 years, case IV: 50 years) underwent urgent laparotomy for acute abdomen due to bowel obstruction (all cases) and peritonitis (cases II, III). Right colon volvulus in cases I, II and IV, ileocolonic intussusception in case II, gaseous distension of bowel loops and abdominal abscess in case III, and enlargement of the entire colon and megasigmoid in case IV were revealed by preoperative imaging. Symptoms of severe abdominal pain, abdominal distension with tenderness, vomiting and complete constipation were evident in all cases. At surgery, features of malrotation, mainly lack of fixation of the right colon which was volvulised, were found in all cases. Right-sided small intestine and Meckel’s diverticulum abscess were found in case III, and an incompletely volvulised megasigmoid coexisted in case IV. We performed resection of peritoneal bands, right hemicolectomy with ileotransversostomy in cases I, II and IV, and enterectomy and right colon fixation in case III. A Hartmann’s sigmoidectomy completed the operation in case IV.
Results
All cases had uneventful outcome, except for some delay in wound healing in a diabetic patient. Histology revealed ischaemia in all segments excised, ileocolonic intussusception associated with a caecal adenocarcinoma in case II, and inflammed Meckel’s diverticulum in case III.
Conclusions
Adult bowel malrotation complicated with right colon volvulus and/or ileocolonic intussusception requires emergent surgery.
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References
Spitz L. Neonatal intestinal obstruction and intussusception in childhood. In: Schwartz SI and Ellis H. Maingot’s abdominal operations. Norwalk, Connecticut: Appleton-Century-Crofts, 1985. pp. 1025–84.
Spigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg 1990;25:1139–42.
Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery 2011;149:386–93.
Hanna T, Akoh JA. Acute presentation of intestinal malrotation in adults: a report of two cases. Ann R Coll Surg Engl 2010;92:W15–8.
Zheng ZH, Huang JL, Wei HB, et al. Adult congenital intestinal malrotation accompanied by midgut volvulus: report of eight cases. Int J Clin Exp Med 2014;7:1614–8. eCollection 2014.
Chuang PW, Huang BM, Liu CH, et al. Left-Sided Appendicitis in an Elderly Patient with Midgut Malrotation. Indian J Surg 2015;77(Suppl 3):1418–20.
Alessandri G, Amodio A, Landoni L, et al. Recurrent acute pancreatitis in bowel malrotation. Eur Rev Med Pharmacol Sci 2016;20:4719–24.
Zengin A, Uçar Bİ, Düzgün ŞA, et al. Adult midgut malrotation presented with acute bowel obstruction and ischemia. Int J Surg Case Rep 2016;22:5–7.
Zissin R, Rathaus V, Oscadchy A, et al. Intestinal malrotation as an incidental finding on CT in adults. Abdom Imaging 1999;24:550–5.
Singla AA, Rajaratnam J, Singla AA, et al. Unusual presentation of left sided acute appendicitis in elderly male with asymptomatic midgut malrotation. Int J Surg Case Rep 2015;17:42–4.
Gamblin TC, Stephens RE Jr, Johnson RK, et al. Adult malrotation: a case report and review of the literature. Curr Surg 2003;60:517–20.
Tirol FT. Cecocolic torsion: Classification, pathogenesis, and treatment. JSLS 2005;9:328–34.
Haak BW, Bodewitz ST, Kuijper CF, et al. Intestinal malrotation and volvulus in adult life. Int J Surg Case Rep 2014;5:259–61.
Hsu CG, Berger A, Shulman A, et al. Intestinal Necrosis with Midgut Malrotation and Intermittent Volvulus: Presentation as Acute Abdominal Pain in an Adult. J Emerg Med 2016;51:326–8.
Naidoo S, Kimmie F, Bhyat A. Intestinal volvulus after conservative management of incidental midgut malrotation discovered at laparoscopic appendectomy in a teenager. S Afr J Surg 2016;54:43.
Yap D, Hassall J, Williams GL, et al. Appendiceal mucocoele with midgut malrotation. Ann R Coll Surg Engl 2016;98:e138–40.
De Raet J, Brugman T, Geukens A. “Twist & slide” bowel obstruction: two different rare causes of adult bowel obstruction in the same patient. Acta Chir Belg 2006;106:608–10.
Balthazar EJ. Congenital positional anomalies of the colon: radiographic diagnosis and clinical implications. II. Abnormalities of fixation. Gastrointest Radiol 1977;2:49–56.
Moldrem AW, Papaconstantinou H, Broker H, et al. Late presentation of intestinal malrotation: An argument for elective repair. World J Surg 2008;32:1426–31.
Avgoustou C, Papazoglou A, Apessou D, et al. Synchronous acute ileocaecocolonic intussusception and right colon volvulus associated with caecal adenocarcinoma and malrotation in an elder. Chirurgia (Minerva) 2014;27:163–6.
Frantzides CT, Cziperle DJ, Soergel K, et al. Laparoscopic ladd procedure and cecopexy in the treatment of malrotation beyond the neonatal period. Surg Laparosc Endosc 1996;6:73–5.
Matzke GM, Dozois EJ, Larson DW, et al. Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Surg Endosc 2005;19:1416–19.
Ruiz-Tovar J, Calero García P, Morales Castiñeiras V, et al. Caecal volvulus: presentation of 18 cases and review of literature. Cir Esp 2009;85:110–4.
Scott CD, Trotta BM, Dubose JJ, et al. A cruel twist: postoperative cecal volvulus. Ulus Travma Acil Cerrahi Derg 2008;14:158–62.
Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. J Am Coll Surg 1999;188:390–5.
Martin MJ, Steele SR. Twists and turns: A practical approach to volvulus and intussusception. Scand J Surg 2010;99:93–102.
Gollub MJ. Colonic intussusception: clinical and radiographic features. Am J Roentgenol 2011;196:W580–5.
Mulas C, Bruna M, Garcia-Armengol J, et al. Management of colonic volvulus. Experiences in 75 patients. Rev Esp Enferm Dig 2010;102:239–48.
Fu T, Tong WD, He YJ, et al. Surgical management of intestinal malrotation in adults. World J Surg 2007;31:1797–803
Tuech JJ, Pessaux P, Regenet N, et al. Results of resection for volvulus of the right colon. Tech Coloproctol 2002;6:97–9.
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Avgoustou, C., Manatakis, D. Acute surgical abdomen as presentation of undiagnosed midgut malrotation in adults. Hellenic J Surg 89, 100–108 (2017). https://doi.org/10.1007/s13126-017-0391-5
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DOI: https://doi.org/10.1007/s13126-017-0391-5