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Should children with non-bilious vomiting and malrotation undergo a Ladd’s procedure or be managed conservatively?
  1. David Colvin1,
  2. Thomas Bourke2,3,
  3. Andrew Thompson2,
  4. Alistair C Dick1
  1. 1 Department of Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, UK
  2. 2 Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
  3. 3 Department of Medical Education, Queen’s University of Belfast: Faculty of Medicine, Health and Life Sciences, Belfast, UK
  1. Correspondence to Mr David Colvin, Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast BT12 6BE, UK; david.colvin{at}belfasttrust.hscni.net

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Scenario

A 2-year-old boy attends outpatient clinic with a history of persistent, intermittent non-bilious vomiting from birth. An upper gastrointestinal (UGI) contrast study was arranged, and the radiology report has stated that the duodenal-jejunal flexure is midline and lower than the gastric outlet, suggesting malrotation without volvulus.

Structured clinical question

Should (patient) children with non-bilious vomiting and radiological evidence of malrotation (intervention) undergo a Ladd’s procedure or (comparison) be managed conservatively (outcome) to reduce the risk of volvulus?

Search

We performed an online literature search in March 2019 using PubMed. The key terms were ‘malrotation’ and ‘asymptomatic’. The search was limited to full articles written in English and yielded 109 results. On review of titles and abstracts, we excluded all case reports, studies not including children and papers focusing on heterotaxy syndromes. Nine studies were identified along with an expert consensus review commissioned by the American Pediatric Surgical Association (APSA). These articles are outlined in table 1 and are graded according to the Oxford levels of evidence.

View this table:
Table 1: Summary of included articles

Commentary

During normal fetal development, the bowel undergoes a 270° counter-clockwise turn, resulting in the duodenal-jejunal flexure (DJF) positioning itself to the left of the midline and at the level of the gastric outlet. It is fixed in position by the ligament of Trietz. From there, the remainder of the small bowel continues …

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