# Malrotation — GCMD Library living collection

Everything in the library about malrotation — built automatically from dossiers that name it.

Updated: n/a · 6 episodes · 108 cited statements

## Episodes
### Surgical Management
- [Malrotation Infant](https://library.globalcastmd.com/watch/malrotation-infant-11940) — video · 9:22 · [machine version](https://library.globalcastmd.com/watch/malrotation-infant-11940.md)

### Case-Based Learning
- [Malrotation](https://library.globalcastmd.com/watch/malrotation-629) — video · 42:31 · [machine version](https://library.globalcastmd.com/watch/malrotation-629.md)
- [Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673) — video · 27:04 · [machine version](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673.md)
- [Malrotation Rapid Fire Session: Update Course 2015](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879) — video · 8:59 · [machine version](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879.md)
- [The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682) — podcast · 8:42 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682.md)

### In-Depth Reviews
- [Malrotation with Dr. Meera Kotagal](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621) — podcast · 13:25 · [machine version](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621.md)

## Chapters
- [0:02](https://library.globalcastmd.com/watch/malrotation-629?t=2) Case 1: Teenager with transient symptoms and malrotation on imaging (Ep 1)
- [2:58](https://library.globalcastmd.com/watch/malrotation-629?t=178) Management options and risk stratification for asymptomatic malrotation (Ep 1)
- [9:51](https://library.globalcastmd.com/watch/malrotation-629?t=591) Case 2: Cardiac infant with feeding difficulties and possible malrotation (Ep 1)
- [16:56](https://library.globalcastmd.com/watch/malrotation-629?t=1016) Imaging interpretation and mesenteric width assessment (Ep 1)
- [19:57](https://library.globalcastmd.com/watch/malrotation-629?t=1197) Case 3: Same cardiac infant with clear malrotation on imaging (Ep 1)
- [24:20](https://library.globalcastmd.com/watch/malrotation-629?t=1460) Case 4: Toddler with non-bilious emesis and redundant duodenum (Ep 1)
- [33:32](https://library.globalcastmd.com/watch/malrotation-629?t=2012) International perspective on asymptomatic malrotation management (Ep 1)
- [37:56](https://library.globalcastmd.com/watch/malrotation-629?t=2276) Case 5: Situs inversus with malrotation and technical challenges (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=0) Malrotation in Heterotaxy Syndrome (Ep 2)
- [8:18](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=498) Meconium Ileus Management (Ep 2)
- [16:47](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1007) Solid Organ Injury: Early Discharge Protocol (Ep 2)
- [25:21](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1521) Pseudoaneurysm Follow-up Discussion (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=0) Case presentation: 6-year-old with heterotaxy, situs inversus, and suspected malrotation (Ep 3)
- [2:35](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=155) Panel discussion: observation versus laparoscopic exploration (Ep 3)
- [4:28](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=268) Literature review and appendectomy debate (Ep 3)
- [7:08](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=428) Rapid-fire case: low-lying ligament of Treitz with normal C-loop (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=0) Introduction and Case Recap (Ep 4)
- [1:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=90) Initial Imaging Interpretation (Ep 4)
- [4:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=240) Differential Diagnosis and Upper GI (Ep 4)
- [4:55](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=295) Contrast Enema and Perforation Risk (Ep 4)
- [6:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=404) Operative Planning and Conclusion (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=0) Introduction and Overview of Malrotation Epidemiology (Ep 5)
- [1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77) Embryologic Development and Anatomic Spectrum of Rotation Abnormalities (Ep 5)
- [3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229) Complications, Clinical Presentation, and Diagnostic Approach (Ep 5)
- [8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513) Surgical Management: Detorsion and Ladd Procedure (Ep 5)
- [12:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=737) Summary and Closing (Ep 5)
- [0:00](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=0) Case presentation and room setup (Ep 6)
- [0:47](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=47) Initial dissection and proximal duodenal mobilization (Ep 6)
- [2:56](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=176) Division of Ladd bands and colonic mobilization (Ep 6)
- [5:18](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=318) Posterior duodenal mobilization and straightening (Ep 6)
- [7:31](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=451) Bowel derotation (Ep 6)
- [8:46](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=526) Appendectomy and final positioning (Ep 6)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "In the first two months of life, about 70% of volvulus cases occur, and by the first two years of life, 90% of volvulus cases that are going to occur do occur" (epidemiological) [Ep 1 · 27:23](https://library.globalcastmd.com/watch/malrotation-629?t=1643)
- "In 20% of cases with true malrotations of the fore and mid-gut, you have a normal barium enema" (clinical) [Ep 1 · 19:27](https://library.globalcastmd.com/watch/malrotation-629?t=1167)
- "A normal ultrasound does not rule out volvulus, supported by multiple studies" (clinical) [Ep 1 · 19:44](https://library.globalcastmd.com/watch/malrotation-629?t=1184)
- "Ladd's bands do not cause midgut volvulus" — Jack (clinical) [Ep 1 · 4:02](https://library.globalcastmd.com/watch/malrotation-629?t=242)
- "Ladd's bands are thought to be an attempt of the body to fuse the cecum to the lateral peritoneal wall" — Wit (clinical) [Ep 1 · 37:16](https://library.globalcastmd.com/watch/malrotation-629?t=2236)
- "The key reason to operate on an asymptomatic patient is to avoid midgut volvulus" — Jack (clinical) [Ep 1 · 3:52](https://library.globalcastmd.com/watch/malrotation-629?t=232)
- "The critical measurement is the distance between the ligament of Treitz and the ileocecal junction to prevent volvulus, though nobody knows the exact distance required" — Jack (clinical) [Ep 1 · 4:56](https://library.globalcastmd.com/watch/malrotation-629?t=296)
- "In patients with heterotaxy syndromes who have asymptomatic malrotations and undergo operations, the complication rate is remarkably high, between 30 and 50%" (epidemiological) [Ep 1 · 16:13](https://library.globalcastmd.com/watch/malrotation-629?t=973)
- "In a study from Edmonton on heterotaxy patients who underwent procedures for malrotation, the complication rate was about 50%" (host_summary) [Ep 1 · 24:59](https://library.globalcastmd.com/watch/malrotation-629?t=1499)
- "In a study by Papillon from Children's LA of about 200 heterotaxy patients, a quarter got screening upper GIs and three quarters did nothing; in 4 years there was only one case of volvulus, and in patients without bilious emesis and symptoms, no cases of volvulus" (host_summary) [Ep 1 · 25:12](https://library.globalcastmd.com/watch/malrotation-629?t=1512)
- "In the heterotaxy subgroup, the risk of volvulus in the early period (4-5 years) is actually very low if patients are not symptomatic" (epidemiological) [Ep 1 · 25:53](https://library.globalcastmd.com/watch/malrotation-629?t=1553)
- "When bowel loops are dilated, this will always give you a low-lying ligament of Treitz" — Todd Ponsky (clinical) [Ep 1 · 11:53](https://library.globalcastmd.com/watch/malrotation-629?t=713)
- "Atypical malrotation with a low-lying ligament of Treitz has some data showing lower risk of volvulus, though the data is not strong" (clinical) [Ep 1 · 16:35](https://library.globalcastmd.com/watch/malrotation-629?t=995)
- "In patients with rotation abnormalities, reversed mesenteric vessels may or may not be seen; it doesn't definitively indicate malrotation" — Jack (clinical) [Ep 1 · 41:01](https://library.globalcastmd.com/watch/malrotation-629?t=2461)
- "In Jack's series of several hundred patients, there was never a case where the vessels were normal in a patient who had risk for volvulus (narrow base mesentery), so they use it as a screening test in sick patients" — Jack (clinical) [Ep 1 · 41:15](https://library.globalcastmd.com/watch/malrotation-629?t=2475)
- "Upper GI is clearly better than ultrasound for diagnosing malrotation, but in a sick patient who can't get to radiology, ultrasound can be useful" — Jack (clinical) [Ep 1 · 41:54](https://library.globalcastmd.com/watch/malrotation-629?t=2514)
- "Laparoscopic Ladd's procedure can be very effective even in a newborn, though if there's too much twist and no room, conversion to open may be necessary" — Tim Kane (clinical) [Ep 1 · 8:18](https://library.globalcastmd.com/watch/malrotation-629?t=498)
- "In cardiac patients between first stage and Glenn procedure who get G-tubes, Nissen fundoplication is often requested because they vomit and are too small for PEGs" — Tim Kane (clinical) [Ep 1 · 14:42](https://library.globalcastmd.com/watch/malrotation-629?t=882)
- "A 45-minute Nissen at pressures of 8 is tolerated by cardiac patients between stages" — Tim Kane (clinical) [Ep 1 · 14:56](https://library.globalcastmd.com/watch/malrotation-629?t=896)
- "In a published study combining experience with Kansas City, the cardiac risk group did not stratify out to be at higher risk for reflux complications; neurologically impaired CP kids maybe, but not cardiac kids" — Todd Ponsky (host_summary) [Ep 1 · 15:15](https://library.globalcastmd.com/watch/malrotation-629?t=915)
- "Yama does not operate on asymptomatic malrotation as long as the patient has non-bilious vomiting, is gaining weight, and is clinically well" — Todd Ponsky (host_summary) [Ep 1 · 35:20](https://library.globalcastmd.com/watch/malrotation-629?t=2120)
- "If a patient has a narrow pedicle, the patient always has vomiting and is symptomatic" — Todd Ponsky (host_summary) [Ep 1 · 36:16](https://library.globalcastmd.com/watch/malrotation-629?t=2176)
- "Ladd's bands themselves are not risky; the risk is bilious vomiting and narrowing of the pedicle" — Todd Ponsky (host_summary) [Ep 1 · 36:39](https://library.globalcastmd.com/watch/malrotation-629?t=2199)
- "In situs inversus or ambiguous cases, measuring the distance between ligament of Treitz and ileocecal junction matters regardless of where the bowels are; if less than half the diameter of the abdominal cavity, intervention is needed" — Jack (clinical) [Ep 1 · 39:27](https://library.globalcastmd.com/watch/malrotation-629?t=2367)
- "In heterotaxy syndrome with right atrial isomerism, there is a higher incidence of malrotation compared to left atrial isomerism." — Todd Ponsky (epidemiological) [Ep 2 · 3:54](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=234)
- "In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery." — Kenneth Azarow (host_summary) [Ep 2 · 5:57](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=357)
- "In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up." — Kenneth Azarow (host_summary) [Ep 2 · 6:20](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=380)
- "Appendectomy carries a slight long-term complication rate from adhesions." — Kenneth Azarow (clinical) [Ep 2 · 6:56](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=416)
- "A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation." — Kenneth Azarow (clinical) [Ep 2 · 8:59](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=539)
- "Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts." — Kenneth Azarow (host_summary) [Ep 2 · 14:41](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=881)
- "To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required." — Kenneth Azarow (host_summary) [Ep 2 · 14:41](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=881)
- "63% of successful meconium ileus enemas require more than one attempt in radiology." — Kenneth Azarow (host_summary) [Ep 2 · 15:11](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=911)
- "If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously." — Kenneth Azarow (opinion) [Ep 2 · 15:36](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=936)
- "Many radiologists have switched from gastrografin to isotonic contrast (such as iohexol) for meconium ileus enemas, which defeats the therapeutic purpose of the enema." — Todd Ponsky (clinical) [Ep 2 · 12:12](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=732)
- "Radiologists avoid gastrografin due to concerns about the hypertonicity of the contrast medium." — Todd Ponsky (clinical) [Ep 2 · 12:29](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=749)
- "Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus." — Kenneth Azarow (host_summary) [Ep 2 · 16:19](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=979)
- "Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade." — Kenneth Azarow (guideline) [Ep 2 · 19:08](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1148)
- "Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols." — Kenneth Azarow (clinical) [Ep 2 · 19:17](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1157)
- "Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability." — Kenneth Azarow (clinical) [Ep 2 · 20:34](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1234)
- "Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours." — Kenneth Azarow (clinical) [Ep 2 · 20:52](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1252)
- "A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital." — Kenneth Azarow (clinical) [Ep 2 · 21:13](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1273)
- "Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment." — Kenneth Azarow (host_summary) [Ep 2 · 22:55](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1375)
- "Activity restrictions after solid organ injury follow the grade plus 2 weeks rule (e.g., grade 3 injury = 5 weeks restriction)." — Todd Ponsky (guideline) [Ep 2 · 23:18](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1398)
- "Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen." — Kenneth Azarow (opinion) [Ep 2 · 23:49](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1429)
- "In adults, 2 centimeters is the cutoff size for mesenteric vessel pseudoaneurysms at which intervention is typically considered." — Todd Ponsky (guideline) [Ep 2 · 26:19](https://library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1579)
- "In heterotaxy syndrome with volvulus, operative intervention is mandatory." (clinical) [Ep 3 · 0:16](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=16)
- "In right atrial isomerism, there is a higher incidence of malrotation compared to left atrial isomerism." (epidemiological) [Ep 3 · 2:44](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=164)
- "In the speaker's institutional data, children with right atrial isomerism were the ones that developed volvulus." (epidemiological) [Ep 3 · 3:26](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=206)
- "Only one patient with left atrial isomerism had any real issues, and it was not a true volvulus." (epidemiological) [Ep 3 · 3:43](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=223)
- "Failure to thrive should be considered a GI symptom warranting laparoscopic exploration to divide Ladd bands and perform appendectomy in heterotaxy patients." (opinion) [Ep 3 · 3:50](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=230)
- "In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd procedure with no post-operative volvulus but 11% small bowel obstruction rate requiring admission and often surgery." (host_summary) [Ep 3 · 4:38](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=278)
- "In the Texas Children's series, 25% of heterotaxy patients were observed with no small bowel obstruction and no volvulus over 10-15 year follow-up." (host_summary) [Ep 3 · 5:10](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=310)
- "Appendectomy is not without its long-term obstruction rate from adhesions." (clinical) [Ep 3 · 5:46](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=346)
- "In situs inversus with malrotation, the appendix is in the correct location (a double negative), so appendectomy may not be indicated." — Todd Ponsky (opinion) [Ep 3 · 5:57](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=357)
- "In heterotaxy, the cecum will be floppy, warranting inversion appendectomy if laparoscopy is performed." (opinion) [Ep 3 · 6:10](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=370)
- "Malrotation is defined by low-lying ligament of Treitz, not by structures crossing the midline, as structures can be floppy and cross midline without excluding malrotation." (clinical) [Ep 3 · 7:46](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=466)
- "The speaker has seen 3-4 cases (in addition to half a dozen during fellowship) where a good C-loop crossed midline but the patient had low-lying ligament of Treitz and was malrotated on exploration." (epidemiological) [Ep 3 · 8:01](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=481)
- "A baby with low-lying ligament of Treitz and reassuring imaging was observed and subsequently returned with volvulus." (clinical) [Ep 3 · 8:36](https://library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=516)
- "Malrotation occurs in about 1 in 200 to 500 live births." — Em Tombash (host_summary) [Ep 5 · 0:28](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=28)
- "In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis." — Meera Kotagal (clinical) [Ep 5 · 1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77)
- "Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant." — Meera Kotagal (clinical) [Ep 5 · 1:44](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=104)
- "Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation." — Meera Kotagal (clinical) [Ep 5 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation." — Meera Kotagal (clinical) [Ep 5 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure." — Meera Kotagal (clinical) [Ep 5 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus." — Meera Kotagal (clinical) [Ep 5 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery)." — Meera Kotagal (clinical) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus." — Meera Kotagal (epidemiological) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 70% of those who will have a midgut volvulus will present in the first year of life." — Meera Kotagal (epidemiological) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases." — Meera Kotagal (clinical) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy." — Meera Kotagal (clinical) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses." — Meera Kotagal (clinical) [Ep 5 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Midgut volvulus is considered the number one surgical emergency in pediatric surgery." — Meera Kotagal (opinion) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability." — Meera Kotagal (clinical) [Ep 5 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation." — Em Tombash (host_summary) [Ep 5 · 8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513)
- "The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible." — Meera Kotagal (clinical) [Ep 5 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms." — Meera Kotagal (clinical) [Ep 5 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease." — Meera Kotagal (epidemiological) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic approach may reduce the risk of postoperative bowel obstruction." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly." — Meera Kotagal (clinical) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion." — Meera Kotagal (opinion) [Ep 5 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "The infant presented with repetitive bilious vomiting." (host_summary) [Ep 6 · 0:00](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=0)
- "An upper GI series showed a redundant duodenum which did not cross the midline." (host_summary) [Ep 6 · 0:09](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=9)
- "The surgeon is positioned at the end of the table with the baby brought down to the foot of the table to allow the surgeon to be in line with the foregut." (host_summary) [Ep 6 · 0:16](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=16)
- "A 4 or 5 millimeter port is placed in the umbilicus, and right and left hand operating ports are placed either side of the umbilicus." (host_summary) [Ep 6 · 0:28](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=28)
- "In a small infant, the right hand port is placed above the umbilicus so that the right hand does not conflict with the scope." (host_summary) [Ep 6 · 0:36](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=36)
- "The 3 millimeter sealer can be used to safely grasp the bowel and act as a forceps which is atraumatic to the bowel." (clinical) [Ep 6 · 1:00](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=60)
- "The first portion of the duodenum is extremely dilated." (clinical) [Ep 6 · 1:22](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=82)
- "Dense adhesions to the proximal duodenum can be safely taken down using the sealer by dissecting them off the bowel and then sealing and gently tearing them off the surface of the duodenum." (clinical) [Ep 6 · 1:33](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=93)
- "Because of the minimal energy spread of the sealer, it is very safe to dissect in this fashion." (clinical) [Ep 6 · 1:51](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=111)
- "The bowel can be grasped immediately after the sealer is activated without any evidence of any heat injury to the bowel." (clinical) [Ep 6 · 1:58](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=118)
- "The sealer is found to be much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bowel." (opinion) [Ep 6 · 2:10](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=130)
- "As is common in these cases, the duodenum goes towards the retroperitoneum, and this is the most difficult part to mobilize." (clinical) [Ep 6 · 3:13](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=193)
- "Adhesions between the transverse colon and the duodenum, some of which are consistent with Ladd bands, can be extremely thick and dense and difficult to take down." (clinical) [Ep 6 · 3:35](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=215)
- "Complete mobilization of the transverse and proximal or ascending colon is necessary because of the posterior attachments." (clinical) [Ep 6 · 4:08](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=248)
- "The minimal energy spread from the sealer allows this device to be used in close proximity to the small bowel without any risk of injury to it." (clinical) [Ep 6 · 5:19](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=319)
- "Ladd bands can traverse across the duodenum causing proximal obstruction." (clinical) [Ep 6 · 5:35](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=335)
- "The posterior retroperitoneal attachment of the duodenum cannot be reached until the Ladd bands have been completely divided." (clinical) [Ep 6 · 7:01](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=421)
- "The bowel is run from proximal to distal to completely derotate the bowel and eliminate the risk of volvulus in the future." (clinical) [Ep 6 · 6:50](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=410)
- "The sealer can act as an atraumatic bowel grasper during bowel running, though the jaws are not quite as large as the 3 millimeter bowel grasper." (clinical) [Ep 6 · 7:39](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=459)
- "The sealer is used during bowel running because other bands are often encountered, and this allows immediate sealing and division." (clinical) [Ep 6 · 7:56](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=476)
- "Enlarged lymph nodes in the mesentery and the chylous appearance within the bowel show evidence of chronic mild obstruction." (clinical) [Ep 6 · 8:29](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=509)
- "At the completion of the Ladd procedure, all of the colon is on the left and the small bowel is on the right." (clinical) [Ep 6 · 8:56](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=536)
- "In a small infant with a small appendix, the appendix can be brought out through the right trocar site and amputated extracorporeally." (clinical) [Ep 6 · 9:06](https://library.globalcastmd.com/watch/malrotation-infant-11940?t=546)
- "A one-day-old full-term infant weighing 3.9 kilograms presented with significant abdominal distension and bilious emesis." — Todd Ponsky (host_summary) [Ep 4 · 0:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=40)
- "If a child is sick with bilious emesis and distension, resuscitation should be the first step before diagnostic workup." — Rod Gerardo (host_summary) [Ep 4 · 2:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=127)
- "The plain abdominal x-ray showed a big right colon, prominent transverse colon, and a compressed left colon with small lumen, along with possible small bowel dilation." (clinical) [Ep 4 · 3:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=196)
- "It is hard on a newborn film to really discern small and large bowel, and you can get fooled." — Frischer (clinical) [Ep 4 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=228)
- "A baby with bilious emesis and non-classic abdominal x-ray could have had distal air and then had a volvulus, requiring urgent upper GI to rule out malrotation before contrast enema." — Todd Ponsky (clinical) [Ep 4 · 4:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=245)
- "A limited upper GI was performed and ruled out malrotation in this child." — Frischer (clinical) [Ep 4 · 4:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=283)
- "The contrast enema showed an impressive right colon with transverse colon tapering off, and a transition zone probably somewhere in the transverse colon." (clinical) [Ep 4 · 5:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=301)
- "Patients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum." — Frischer (clinical) [Ep 4 · 5:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=320)
- "To get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon." — Frischer (clinical) [Ep 4 · 5:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=320)
- "A baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel." — Frischer (clinical) [Ep 4 · 5:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=341)
- "You are obligated at some point, maybe after resuscitation, to get a rectal biopsy in a patient with suspected Hirschsprung disease." — Frischer (clinical) [Ep 4 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=357)
- "If the transition zone is at the hepatic flexure, you can predict that enough pressure builds up in the right colon to have the cecum perforate." (clinical) [Ep 4 · 6:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=364)
- "You rarely get a perforation in a more standard sigmoid level transition zone." (clinical) [Ep 4 · 6:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=364)
- "A suction rectal biopsy confirmed the diagnosis of Hirschsprung disease in this patient." (clinical) [Ep 4 · 6:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=418)
- "Proximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches." — Frischer (clinical) [Ep 4 · 7:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=434)

## Changelog
- Sep 7: 3 items added automatically
- Sep 7: 3 items added automatically

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