Malrotation of the midgut with volvulus - Forum

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Pediatric surg

Malrotation of the midgut with volvulus - Ärzteforum

Post#1 »

I have operated on a 10 day old newborn who came with bilious vomiting for one day. No feeding problems since birth. Upper GI confirmed presence of malrotation. O/E slightly distended abdomen with some tenderness. Good bowel sounds.

OR findings: Malrotation of the midgut with volvulus. Ischemic but viable bowel. Ladd's procedure performed( de-rotation counterclockwise, lysis of Ladd's bends, appendectomy, positioning of SB on right side and large bowel on left side). Proximal bowel: 15 cm of proximal jejunum had borderline viability and no significant improvement in color following de-rotation. This segment was partially devascularized during lysis of Ladd's bands. No resection done. ( I would have resected in adult this kind of bowel). Next day in am baby was looking very well, extubated and bowel signs present. At the end of the day baby got more distended and developed mild metabolic acidosis (PH 7.29, bicabs 18). 2nd look laparotomy done - bowel looked well and viable.

Conclusion:
Pediatric bowel more resistant to ischemia and devascularization. Give more credit to joung bowel.

Any comments? Pediatric experience?


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Surgeon

Re: Malrotation of the midgut with volvulus - Ärzteforum

Post#2 »

Sounds like you did a good job. Neonate and pediatric bowel often will return to 'life' after looking quite awful because of the ability to vasoconstrict to maintain central perfusion. BP drop in children is late sign and means a significant amount of blood loss or fluid loss. Thus questionably viable bowel can be left and reassessed clinically(less accurate) or operatively. In some neonates we have sewn on a bile bag to the abdomen(not closed the abd - like the Bogota bag) to assess the bowel in the ICU directly ( this decompresses the abdomen and allows direct assessment of the bowel).

In your neonate's case the fact he was extubated and doing well immediately post op suggests all is well and he may not have needed the second surgery but better safe than sorry.

A question regarding your practice environment. Do you do both pediatric surgery and adult surgery or was there no pediatric surgeon available? I know not many of our adult surgery colleagues would wish to tackle this in a newborn especially when the child was not in major difficulties but would suggest urgent referral to the local pediatric surgery center. For this sort of problem we have fairly well establish referral bases ie ours is Central West Ontario (pop. 2 million). I wouldn't think in Brooklyn this is a geographical issue.

Pediatric surg

Re: Malrotation of the midgut with volvulus - Ärzteforum

Post#3 »

I am a chief surgical residnet - ( my case) pediatric surgeon was with me of course - I am drawing my own educational conclusions.

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