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Laparoscopic versus open Ladd’s procedure for intestinal malrotation in adults

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Abstract

Background

Intestinal malrotation results from errors in fetal intestinal rotation and fixation. While most patients are diagnosed in childhood, some present as adults. Laparoscopic Ladd’s procedure is an accepted alternative to laparotomy in children but has not been well-studied in adults. This study was designed to investigate outcomes for adults undergoing laparoscopic Ladd’s repair for malrotation.

Methods

We performed a single-institution retrospective chart review over 11 years. Data collected included patient age, details of pre-operative work-up and diagnosis, surgical management, complications, rates of re-operation, and symptom resolution. Patients were evaluated on an intent-to-treat basis based on their planned operative approach. Categorical data were analyzed using Fisher’s exact test. Continuous data were analyzed using Student’s t test.

Results

Twenty-two patients were identified (age range 18–63). Fifteen were diagnosed pre-operatively; of the remaining seven patients, four received an intra-operative malrotation diagnosis during elective surgery for another problem. Most had some type of pre-operative imaging, with computed tomography being the most common (77.3 %). Comparing patients on an intent-to-treat basis, the two groups were similar with respect to age, operative time, and estimated blood loss. Six patients underwent successful laparoscopic repair; three began laparoscopically but were converted to laparotomy. There was a statistically significant difference in hospital length of stay (LOS) (5.0 ± 2.5 days vs 11.6 ± 8.1 days, p = 0.0148) favoring the laparoscopic approach. Three patients required re-operation: two underwent side-to-side duodeno-duodenostomy and one underwent a re-do Ladd’s procedure. Ultimately, three (two laparoscopic, one open) had persistent symptoms of bloating (n = 2), constipation (n = 2), and/or pain (n = 1).

Conclusion

Laparoscopic repair appears to be safe and effective in adults. While a small sample size limits the power of this study, we found a statistically significant decrease in LOS and a trend toward decreased postoperative nasogastric decompression. There were no significant differences in complication rates, re-operation, or persistence of symptoms between groups.

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Acknowledgments

Author Lane Frasier is currently funded under F32 Grant HS022403 through the Agency for Healthcare Research and Quality and the AAS Research Fellowship Award and previously received funding via T32 Grant CA90217 through the NIH National Cancer Institute. Ankush Gosain is funded by the American Pediatric Surgery Association Foundation Award (2013) and NIDDK K08DK098271. This work was supported by grants from NIH, National Cancer Institute; T32 CA90217, F32 HS022403, AAS Research Fellowship Award and K08 (NIDDK K08DK098271).

Disclosures

Dr. Greenberg is a paid consultant for Bard-Davol and Covidien; neither of these relationships are relevant to the content of this manuscript. Authors Frasier, Leverson, and Gosain have no conflicts of interest or financial ties to disclose.

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Correspondence to Jacob Greenberg.

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Frasier, L.L., Leverson, G., Gosain, A. et al. Laparoscopic versus open Ladd’s procedure for intestinal malrotation in adults. Surg Endosc 29, 1598–1604 (2015). https://doi.org/10.1007/s00464-014-3849-3

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  • DOI: https://doi.org/10.1007/s00464-014-3849-3

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