Malrotation with Dr. Meera Kotagal

Published: 2023-05-04

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Em Tom Bash — host
Mira Kotagal — guest

Chapters

0:00Introduction and Epidemiology — Introduction to the podcast topic of malrotation, its incidence (1 in 200-500 live births), and importance as a cause of intestinal obstruction in pediatric patients.
1:17Embryology and Anatomy of Malrotation — Detailed explanation of normal bowel rotation during fetal development (fourth week of gestation through return to abdomen with 90-degree and 270-degree rotations) and the spectrum of rotation abnormalities including non-rotation and malrotation.
3:39Complications, Presentation, and Diagnosis — Discussion of malrotation complications (obstructive symptoms and midgut volvulus), clinical presentation with emphasis on bilious emesis, differential diagnosis, associated conditions (heterotaxy, CDH, gastroschisis, omphalocele), and diagnostic imaging with upper GI as the gold standard.
8:33Surgical Treatment and Controversies — Explanation of surgical management including detorsion and Ladd procedure steps (widening mesentery, relieving duodenal obstruction, appendectomy, non-rotation configuration), debate over laparoscopic versus open approach, and controversy regarding prophylactic Ladd procedures.
12:17Summary and Closing — Recap of key diagnostic and treatment points and podcast conclusion.

Key claims

0:28Malrotation occurs in about 1 in 200 to 500 live births — Em Tom Bash
1:17In the fourth week of gestation, bowel development begins with the bowel herniating into the yolk sac and along the umbilical cord and SMA axis — Mira Kotagal
1:44Normal bowel rotation involves a 90 degree rotation of the duodenal-jejunal loop followed by a 270 degree rotation of the cecum and colon as the bowel returns to the abdominal cavity — Mira Kotagal
1:44Normal anatomy results in the duodenal-jejunal junction to the left of midline at the ligament of Treitz and the cecum in the right lower quadrant — Mira Kotagal
2:22Non-rotation results in the colon on the left and small bowel on the right without the problematic Ladd bands that cause obstruction in malrotation — Mira Kotagal
2:22Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure — Mira Kotagal
2:22Malrotation involves incomplete rotation preventing formation of a broad-based mesentery, which is important to reduce the risk of volvulus — Mira Kotagal
3:49Complications of malrotation fall into two categories: obstructive symptoms with feeding intolerance, and midgut volvulus resulting from narrow mesentery — Mira Kotagal
3:49About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus — Mira Kotagal
3:49About 70% of children who will have a midgut volvulus will present in the first year of life — Mira Kotagal
3:49As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases — Mira Kotagal
3:49Children with congenital cardiac disease and heterotaxy commonly have associated malrotation, but their likelihood of symptomatic events is much lower — Mira Kotagal
3:49Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of these diagnoses — Mira Kotagal
4:49In the neonatal period, bilious emesis is the most critical symptom requiring evaluation for midgut volvulus even if the x-ray appears normal — Mira Kotagal
4:49Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension — Mira Kotagal
4:49Late signs of volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia — Mira Kotagal
4:49The differential diagnosis for bilious emesis includes atresia, Hirschsprung disease, meconium ileus, meconium plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis — Mira Kotagal
4:49Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis — Mira Kotagal
6:40Upper GI is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum — Mira Kotagal
6:40On upper GI, normal anatomy shows the C loop of the duodenum coming back across the midline to the left, and on lateral view going posteriorly and cephalad — Mira Kotagal
7:30Contrast enema can sometimes determine cecal position but current sensitivity and specificity are not sufficient to rule out malrotation definitively — Mira Kotagal
7:30Upper GI remains the definitive test for malrotation because missing midgut volvulus is considered the number one surgical emergency in pediatric surgery — Mira Kotagal
8:33Surgical treatment of volvulus involves exploratory laparotomy with evisceration of the bowel and detorsion, usually requiring 270 degree counterclockwise rotation — Mira Kotagal
8:33After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged — Mira Kotagal
8:33You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation — Em Tom Bash
8:54The Ladd procedure involves widening the mesentery by removing Ladd bands, straightening the duodenum to avoid obstruction, and often performing an appendectomy — Mira Kotagal
8:54Appendectomy during Ladd procedure is performed because the appendix will be in an abnormal anatomic position, and families need to be informed if it is left in place — Mira Kotagal
8:54After Ladd procedure, the bowel is placed in non-rotation configuration with small bowel on the right and large bowel on the left to keep the mesentery as broad as possible — Mira Kotagal
10:01Some believe that part of the benefit of Ladd procedure is causing scar tissue that helps the bowel adhere in a configuration preventing midgut volvulus — Mira Kotagal
10:01Laparoscopic Ladd procedure may have decreased adhesion rates, potentially reducing the adhesive benefit but also potentially reducing postoperative bowel obstruction — Mira Kotagal
10:01About a quarter of patients who undergo a Ladd procedure will have intestinal obstruction related to adhesive small bowel disease — Mira Kotagal
10:01In older children with symptomatic malrotation, laparoscopic approach may be started to assess mesentery width and duodenal anatomy before deciding on approach — Mira Kotagal
10:01There is controversy about whether laparoscopic approach can successfully broaden the mesentery as wide as it should be — Mira Kotagal
10:01There is controversy about whether prophylactic Ladd procedure should be performed in asymptomatic children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia — Mira Kotagal
10:01In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly — Mira Kotagal
10:01Decisions about prophylactic Ladd procedure should involve informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care — Mira Kotagal

Open questions

What is the optimal approach (laparoscopic vs. open) for Ladd procedure to balance adhesion formation benefits against postoperative bowel obstruction risk?
Should prophylactic Ladd procedures be performed in asymptomatic children with diagnosed malrotation or associated conditions like congenital diaphragmatic hernia?
Can laparoscopic technique adequately widen the mesentery compared to open approach?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Malrotation: When Normal Bowel Development Goes Wrong

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Discipline

Malrotation is not a single defect but a spectrum of anatomic variants arising from incomplete fetal bowel rotation. It matters clinically because it creates two distinct problems: chronic duodenal obstruction from abnormal peritoneal bands, and the acute catastrophe of midgut volvulus — twisting of the entire small bowel on a narrow mesenteric pedicle, cutting off its blood supply. About 1 in 200 to 500 live births involve some degree of malrotation 0:28, but only 1 in 30 of those children will ever develop volvulus 3:49. The challenge is identifying which children are at risk and when intervention is justified, because the operation to prevent volvulus itself carries risk of subsequent bowel obstruction from adhesions 10:01.

The Core Problem

Normal bowel rotation occurs in two stages during the fourth week of gestation. The developing intestine herniates into the umbilical cord along the superior mesenteric artery axis 1:17. As it returns to the abdomen, the duodenal-jejunal loop rotates 90 degrees, then the cecum and colon rotate 270 degrees 1:44. This choreography positions the duodenal-jejunal junction at the ligament of Treitz on the left and the cecum in the right lower quadrant, spreading the small bowel mesentery from left upper to right lower quadrant — a broad base that resists twisting 1:44.

Malrotation means incomplete rotation, leaving a narrow mesenteric pedicle 2:22. The cecum may stop partway across the abdomen, and peritoneal bands (Ladd bands) stretch from the abnormally positioned cecum across the duodenum, potentially obstructing it. The narrow mesentery allows the entire midgut to twist on itself — midgut volvulus — strangling the blood supply to everything the superior mesenteric artery feeds.

Non-rotation, by contrast, means no rotation at all: small bowel on the right, colon on the left, no obstructing bands 2:22. This configuration is stable and rarely symptomatic, which is why surgeons intentionally recreate it during the Ladd procedure 2:22.

How the Approach Works

Recognition. Bilious emesis in a neonate is malrotation until proven otherwise 4:49. Even with a normal abdominal radiograph, upper GI study is mandatory 4:49. The differential for bilious emesis is broad — atresia, Hirschsprung disease, meconium ileus, incarcerated hernia, necrotizing enterocolitis — but malrotation must be excluded first because midgut volvulus is considered the number one surgical emergency in pediatric surgery 7:30. As one of the discussants noted, you can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation 8:33.

Older children may present with feeding intolerance, intermittent abdominal pain, or distension 4:49. Late signs — bloody stools, peritoneal signs, abdominal wall erythema — indicate established intestinal ischemia and represent a surgical catastrophe in progress 4:49.

Diagnosis. Upper GI series is the gold standard 6:40. The study must visualize the entire C-loop of the duodenum crossing back to the left of midline and, on lateral view, coursing posteriorly and cephalad 6:40. Contrast enema showing cecal position is insufficient to rule out malrotation given the stakes of missing volvulus 7:30.

Surgical management. Midgut volvulus requires immediate laparotomy. The bowel is eviscerated and detorsed — typically 270 degrees counterclockwise 8:33 — then allowed to rest while the surgeon assesses viability 8:33. If the bowel recovers, the operation proceeds to the Ladd procedure. If it does not, resection may be necessary, though surgeons often perform a second-look laparotomy before committing to massive resection.

The Ladd procedure addresses the anatomic substrate of malrotation. First, Ladd bands are divided to widen the mesentery 8:54. Second, the duodenum is straightened to relieve obstruction 8:54. Third, appendectomy is typically performed because the appendix will be in an abnormal position, and families must be informed if it is left in place 8:54. Finally, the bowel is arranged in non-rotation configuration — small bowel right, colon left — to maintain the broadest possible mesenteric base 8:54.

Where Practice Is Contested

Laparoscopic versus open Ladd procedure remains debated. Some believe the Ladd procedure works partly by creating adhesions that fix the bowel in a configuration preventing volvulus 10:01. Laparoscopic surgery produces fewer adhesions, which might reduce the protective effect but also might reduce the risk of postoperative bowel obstruction from adhesive disease 10:01 10:01. One approach is to start laparoscopically in older, non-acute cases, assess mesenteric width and duodenal anatomy, then decide whether to proceed laparoscopically or convert to open. There is genuine uncertainty about whether laparoscopy can achieve adequate mesenteric broadening 10:01.

Prophylactic Ladd procedure in asymptomatic malrotation is even more contentious 10:01. About 70% of children who will develop volvulus present in the first year of life 3:49, and the risk declines with age 3:49. In infants, the calculus often favors surgery. In older children, particularly those with heterotaxy or congenital heart disease — who have high rates of incidental malrotation but low rates of symptomatic events 3:49 — the decision is less clear. The discussants emphasize informed consent discussions that weigh the risks of both operating and not operating, considering factors like access to emergency care 10:01.

When to Involve This Team

Any neonate with bilious emesis requires immediate pediatric surgical consultation and upper GI study. Do not wait for imaging to call. In children with congenital diaphragmatic hernia, gastroschisis, or omphalocele, malrotation is expected 3:49; discuss timing of evaluation with the surgical team. In children with heterotaxy or complex congenital heart disease, malrotation is common but often asymptomatic 3:49; coordinate evaluation with cardiology and surgery. For older children with chronic abdominal pain or feeding intolerance, consider malrotation in the differential, particularly if symptoms are intermittent or meal-related.

Takeaways from this story

Bilious emesis in a neonate mandates upper GI study even with normal x-ray — midgut volvulus is a surgical emergency.
Only 1 in 30 children with malrotation develop volvulus, and 70% of those present in the first year of life.
The Ladd procedure creates non-rotation anatomy (small bowel right, colon left) to widen the mesentery and prevent volvulus.
Ladd procedure carries risk of adhesive bowel obstruction, complicating risk-benefit decisions in asymptomatic cases.
Children with heterotaxy have high rates of malrotation but low rates of symptomatic volvulus, making prophylactic surgery controversial.

Malrotation and Midgut Volvulus: When Embryologic Rotation Goes Wrong

For trainees · Explainer · AI-written, human-reviewed

Why This Exists as a Discipline

Intestinal malrotation is not a subspecialty problem — it is a core pediatric surgical emergency that general pediatricians, emergency physicians, and neonatologists must recognize. It exists at the intersection of embryology and acute care because a developmental anomaly that occurs in the fourth week of gestation can suddenly become life-threatening at any point in childhood. The discipline of pediatric surgery carved out specific expertise here because the stakes are absolute: missing midgut volvulus means losing bowel 7:30.

The Core Problem

Normal bowel rotation occurs in two stages during fetal development. The bowel herniates into the yolk sac along the SMA axis, then returns to the abdomen with a 90-degree rotation of the duodenal-jejunal loop followed by a 270-degree rotation of the cecum and colon 1:44. This produces the anatomy you expect: duodenal-jejunal junction at the ligament of Treitz on the left, cecum in the right lower quadrant, and a broad-based mesentery spanning from left upper to right lower quadrant 1:44.

Malrotation means incomplete rotation. The mesentery remains narrow, creating a pedicle that can twist on itself — midgut volvulus 2:22. The bowel may also develop Ladd bands: peritoneal attachments that cross and obstruct the duodenum 3:49. The clinical threat is twofold: chronic duodenal obstruction causing feeding intolerance, and acute volvulus causing intestinal ischemia.

The epidemiology matters for risk stratification. Malrotation occurs in roughly 1 in 200 to 500 live births 0:28. Of those children, only about 1 in 30 will develop volvulus 3:49. Seventy percent of volvulus cases present in the first year of life 3:49, and risk decreases with age if volvulus has not occurred 3:49. This creates a clinical dilemma: most children with malrotation will never have a catastrophic event, but you cannot predict which ones will.

How the Approach Works

Recognition. In a neonate, bilious emesis is malrotation until proven otherwise. Even with a normal-appearing abdominal radiograph, the child requires urgent imaging 4:49. The differential for bilious emesis is broad — atresia, Hirschsprung disease, meconium ileus, incarcerated hernia, necrotizing enterocolitis — but malrotation must be ruled out first 4:49 4:49. Late signs of volvulus include bloody stools, peritoneal signs, and abdominal wall erythema, all indicating intestinal ischemia 4:49. By that point, you are behind.

Diagnosis. Upper GI series is the definitive test 6:40. You must visualize the entire C-loop of the duodenum crossing back to the left of midline; on lateral view, it should course posteriorly and cephalad 6:40. Contrast enema showing cecal position is insufficient — sensitivity and specificity are not adequate to rule out a surgical emergency of this magnitude 7:30 7:30.

Surgical management. Midgut volvulus requires immediate exploratory laparotomy. The bowel is eviscerated and detorsed, typically with a 270-degree counterclockwise rotation 8:33. The surgeon then assesses viability — has ischemia progressed too far 8:33? You cannot have midgut volvulus without malrotation, but you can have malrotation without volvulus 8:33. Once the volvulus is addressed, the Ladd procedure corrects the underlying malrotation.

The Ladd procedure has three components: widen the mesentery by dividing Ladd bands, straighten the duodenum to relieve obstruction, and place the bowel in non-rotation configuration — small bowel on the right, colon on the left 8:54 8:54. Many surgeons perform appendectomy because the appendix will be in an abnormal position, and families must be informed if it remains 8:54. Some believe the procedure works partly by creating adhesions that prevent re-volvulus 10:01, though this means accepting a substantial rate of postoperative small bowel obstruction from adhesive disease 10:01.

Where Practice Is Contested

The laparoscopic versus open debate hinges on whether you believe adhesions are protective or harmful. Laparoscopy may reduce postoperative obstruction but might not widen the mesentery as effectively or create the adhesions some consider beneficial 10:01 10:01. In older children with symptomatic malrotation, some surgeons start laparoscopically to assess mesentery width and duodenal anatomy before committing to an approach 10:01.

The prophylactic Ladd procedure remains controversial. Should you operate on an asymptomatic child with diagnosed malrotation? The answer depends on age, associated conditions, and access to care. Younger children have higher volvulus risk and are more commonly offered surgery 10:01. Children with heterotaxy and congenital heart disease frequently have malrotation but lower rates of symptomatic events 3:49. Families remote from tertiary care may reasonably choose prophylactic surgery, accepting bowel obstruction risk over volvulus risk in a setting where emergency access is limited 10:01.

When to Involve Pediatric Surgery

Bilious emesis in a neonate is an immediate surgical consult, even with a normal radiograph. Do not wait for imaging — call while ordering the upper GI. In older children with feeding intolerance or intermittent abdominal pain, malrotation enters the differential if symptoms are unexplained. Children with congenital diaphragmatic hernia, gastroschisis, omphalocele, or heterotaxy have malrotation by definition and require individualized discussion about timing and necessity of repair 3:49. The threshold for imaging is low because the cost of a missed volvulus is catastrophic.

Takeaways from this story

Bilious emesis in a neonate requires urgent upper GI to rule out malrotation, even with normal radiograph.
Only 1 in 30 children with malrotation develop volvulus, but 70% of volvulus cases occur in the first year.
Upper GI showing duodenum crossing left of midline is definitive; contrast enema is insufficient to rule out malrotation.
Ladd procedure widens mesentery and places bowel in non-rotation configuration but carries risk of adhesive obstruction.
Children with heterotaxy have high malrotation rates but lower symptomatic event rates than isolated malrotation.

Malrotation and Midgut Volvulus: Risk Stratification and Surgical Decision-Making

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Embryology and Anatomic Spectrum

Normal bowel rotation involves a 90-degree rotation of the duodenal-jejunal loop followed by a 270-degree rotation of the cecum and colon as the bowel returns to the abdominal cavity 1:44. This produces the duodenal-jejunal junction to the left of midline at the ligament of Treitz and the cecum in the right lower quadrant 1:44. Malrotation involves incomplete rotation preventing formation of a broad-based mesentery, which increases the risk of volvulus 2:22. Non-rotation results in the colon on the left and small bowel on the right without the problematic Ladd bands that cause obstruction in malrotation 2:22.

Risk Stratification

Malrotation occurs in about 1 in 200 to 500 live births 0:28, but only about one in 30 of those children with malrotation will develop a volvulus 3:49. About 70% of children who will have a midgut volvulus will present in the first year of life 3:49. As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event decreases 3:49. Children with congenital cardiac disease and heterotaxy commonly have associated malrotation, but their likelihood of symptomatic events is much lower 3:49.

Diagnosis

In the neonatal period, bilious emesis is the most critical symptom requiring evaluation for midgut volvulus even if the x-ray appears normal 4:49. Upper GI is the definitive test for malrotation, looking at the position and course of the duodenum 6:40. On upper GI, normal anatomy shows the C loop of the duodenum coming back across the midline to the left, and on lateral view going posteriorly and cephalad 6:40. Contrast enema showing cecal position has insufficient sensitivity and specificity to rule out malrotation definitively 7:30, because missing midgut volvulus is considered the number one surgical emergency in pediatric surgery 7:30.

Surgical Approach

Surgical treatment of volvulus involves exploratory laparotomy with evisceration of the bowel and detorsion, usually requiring 270-degree counterclockwise rotation 8:33. The Ladd procedure involves widening the mesentery by removing Ladd bands, straightening the duodenum to avoid obstruction, and often performing an appendectomy 8:54. After Ladd procedure, the bowel is placed in non-rotation configuration with small bowel on the right and large bowel on the left to keep the mesentery as broad as possible 8:54.

Controversies

There is controversy about whether laparoscopic approach can successfully broaden the mesentery as wide as it should be 10:01. A substantial proportion of patients who undergo a Ladd procedure will have intestinal obstruction related to adhesive small bowel disease 10:01. There is also controversy about whether prophylactic Ladd procedure should be performed in asymptomatic children with diagnosed malrotation 10:01. In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly 10:01.

Takeaways from this story

Only 1 in 30 children with malrotation develop volvulus; 70% of those present in first year of life
Upper GI showing duodenum crossing left of midline is definitive; contrast enema insufficient to rule out malrotation
Bilious emesis in neonate requires volvulus evaluation even with normal x-ray—missing it is the top pediatric surgical emergency
Substantial proportion of Ladd procedures result in adhesive bowel obstruction; laparoscopic approach may reduce this but mesentery widening adequacy is debated

Topic overview

This discussion covers malrotation, a congenital intestinal rotation abnormality occurring in approximately 1 in 200-500 live births. The speakers explain the embryologic basis—normal bowel rotation occurs in two stages (90 degrees then 270 degrees) during weeks 4-10 of gestation, and errors produce a spectrum from non-rotation to malrotation. The critical complication is midgut volvulus, which occurs in roughly 1 in 30 children with malrotation, with 70% presenting in the first year of life. Bilious emesis is the key presenting symptom requiring urgent evaluation via upper GI study, and treatment involves detorsion followed by a Ladd procedure to widen the mesentery and prevent recurrence.

Key takeaways

Bilious emesis in neonates mandates urgent upper GI study to rule out midgut volvulus, even with normal x-ray. (4:49)
70% of midgut volvulus cases present in first year; risk decreases with age if asymptomatic. (3:49)
Upper GI is definitive test for malrotation; contrast enema lacks sensitivity to rule out volvulus reliably. (6:40)
Ladd procedure widens mesentery by removing bands, straightening duodenum, and placing bowel in non-rotation. (8:54)
25% of Ladd patients develop adhesive bowel obstruction; laparoscopic approach may reduce this but remains controversial. (10:01)

Keywords

malrotation midgut volvulus intestinal obstruction non-rotation heterotaxy congenital cardiac disease congenital diaphragmatic hernia gastroschisis omphalocele atresia Hirschsprung disease meconium ileus meconium plug incarcerated hernia anorectal malformation

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Transcript

Click "Show Transcript" to view the full text (15036 characters)

Hi, everyone. Welcome back to Stay Current Podcasts. I'm Em Tom Bash, a research fellow at Cincinnati Children's Hospital Medical Center. And along with Stay Current, we are sharing knowledge to improve child health around the globe. In this podcast, we are going to talk about malrotation anatomy, presentation, diagnosis, and treatment options with Dr. Mira Kodagal. My name is Mira Kodagal. I'm a pediatric surgeon at Cincinnati Children's. We have a lot to cover today. So if you're looking for a specific part like diagnosis or treatment options, make sure to check out time stops in the description. They'll take you wherever you need. Malrotation is a congenital condition that occurs in about 1 in 200 to 500 live births, making it a relatively common issue in pediatric patients. It is one of the most important causes of intestinal obstruction in infants and children. The severity of symptoms can vary, and early diagnosis and treatment are critical to prevent long-term health problems. But before we start talking about diagnosis and treatment, I want to take a step back to understand how malrotation happens anatomically. What are the differences in fetal development that cause malrotation? Now, Dr. Kodagal will explain. In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis. We've all been there. I know it's hard to visualize the anatomy, especially challenging one like malrotation. For this reason, we added some animations linked below in the description. Don't forget to check them out. I promise it'll help you understand the concept better. Dr. Kodagal is the last one. It develops outside and continues to grow in length and then will actually go back into the abdomen with sort of two pieces of rotation. The first part of the rotation is a 90 degree rotation where the duodenal-jejunal loop sort of rotates. And then you get the return of the rest of the bowel into the abdominal cavity with a 270 degree rotation of the cecum and colon. And that allows it to end up in the conformation that we consider it normal, where you have a duodenal-jejunal junction to the left to midline at the ligament of triads. And then the cecum and colon around the abdomen starting from the right lower quadrant all the way around to the left. Now is the time to check the animations link below in the description if you haven't yet. We're now moving on. You can get errors at any stage in that sort of rotational return of the bowel to the abdomen. And those can result in that wide spectrum of anomalies. We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal. Those can include both non-rotation and malrotation. With non-rotation, basically the gut goes back in but doesn't rotate at all. And so you end up with the colon on the left and the small bowel on the right. And you don't tend to have the problematic lads bands that can cause obstruction as you see in malrotation. And so, non-rotation anatomy actually looks a lot like the anatomy of a malrotated kid post lads. Malrotation means that you get some portion of the rotation but you don't necessarily end up with full rotation to allow for the broad-based mesentery, which is what's important to reduce the risk of volvulus. So you can end up with some rotation meaning that the small bowel is still all on the right and the cecum makes it part way towards the right lower quadrant but not the whole way. And so you get lads bands that can be obstructing of that duodenal junction or you can get different sort of anomalies within there. The cecum can still be on the left-hand side but the small bowel mesentery is narrow. And that's what ends up causing your predisposition towards volvulus. Since we mentioned volvulus, we need to look into malrotation complications. What are we afraid of for this kids? Complications of malrotation, there's really two buckets that you have to think about. One are sort of obstructive symptoms and you tend to see that with feeding intolerance and kids that may have issues around food getting past those lads bands in the duodenum. And the other one is midgut volvulus, which is the result of narrow mesentery. When you have malrotation and because of the way that the bowel aligns, the small bowel mesentery is not spread out from the left upper quadrant to the right lower quadrant as you would expect and you can get a narrow pedicle. It's easier for that pedicle to twist on itself and then you get a midgut volvulus and ischemia of the intestine. About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus. A lot of kids with malrotation may never be identified to have malrotation or they may have mild symptoms of feeding intolerance and that may result in their evaluation and diagnosis. It's important to recognize that about 70% of those who will have a midgut volvulus will present in the first year of life. So as kids get older, if they never had a volvulus, their likelihood of having a significant clinical event related to their malrotation goes down. Very commonly kids with congenital cardiac disease and heterotaxy especially can have associated malrotation. The data seems to suggest that in those kids their likelihood of having a symptomatic event, whether that is feeding intolerance and biliosemesis or actually progressing to volvulus, is much lower. So we don't tend to fix the kids who have heterotaxy and malrotation with the same frequency that we might for another child in their infancy. The other thing to remember is that rotational abnormalities are also associated with certain diagnoses that are very commonly seen in pediatric surgery and they're just the result of the nature of the anatomy of those diagnoses. So that includes congenital diaphragmatic hernia, gastroschisis and emphalocele. In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus. You have to be able to really understand that because the risk to missing it is so high. And so biliosemesis is the most common criteria for us to evaluate a kid for malrotation. But there are other things that you can see like feeding intolerance, abdominal pain, abdominal distension. You can get some late signs associated with volvulus, but at that point it's usually reflective of the intestinal ischemia. So you can get bloody stools or peritoneal signs on exam, abdominal wall erythema. All of those are more suggestive of a later stage in the process and concerning for progression of intestinal ischemia. So the differential diagnosis for biliosemesis is actually quite broad and includes basically all kinds of intestinal obstructions. So it includes atresia, Hirschsprung's disease, meconium ileus or meconium plugs, any other cause for intestinal obstruction including things like an incarcerated hernia and anorectal malformations in kids who have no obvious fistula or who have an intestinal fistula to their urinary system or kids with necrotizing enterocolitis. All of those diagnoses in kids can present with biliosemesis and actually for many of them malrotation may be less likely. But it's the thing that you have to rule out before you go down to the pathway of thinking about other diagnoses. The imaging that we use most frequently for the diagnosis of malrotation is an upper GI and you're really there looking at the position and the course of the duodenum in order to determine whether or not it is normally or abnormally positioned. You want to see the total of the C loop and actually watch the duodenum come back across the midline to the left. Also when you look at it from a lateral perspective you want to see it also go posteriorly and a bit cephalad in order to determine that's really normal position of the duodenum and decreases your risk or concern for malrotation. But what about using contrast enema for diagnosing? Some people also think you can use contrast enema sometimes if you're able to determine whether the position of the cecum is normal on a contrast enema. I think our sensitivity and specificity for those studies currently is not sufficient for us to be comfortable using them to rule out a significant pathology, right? We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem and so to this point they haven't superseded upper GI as the definitive test. The surgical treatment of volvulus is to go to the operating room and do an expletive leparotomy. You have to actually detour the bowel. So there's multiple steps when we think about doing a LADS procedure. So there's multiple steps when we think about doing a LADS procedure and a LADS procedure is the last part of an operation for volvulus. You're going to make an incision, you're going to eviscerate the bowel in order to be able to determine what you're dealing with and then de-rotate or de-volvulize the bowel. Which usually requires a 270 degree rotation counterclockwise. And once you've done so then you're able to give the bowel a rest and actually try to see whether it can pick up again or whether that ischemia has been going on so long that you're concerned about the viability of the intestine. So Dr. Cartergal believes that it is really important to distinguish malrotation from volvulus. You can have malrotation which is not a surgical emergency or a mid-gut volvulus which is a surgical emergency and malrotation predisposes you to that mid-gut volvulus. You can't have one without the other but not all kids who have a malrotation are volvulus. So you can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation. And so once you have done the operation in order to de-volvulize the bowel then you can deal with the LADS procedure which is an operation for malrotation. And that involves doing a couple of things. The initial thing is widening the mesentery. You want to try to take off as many of those LADS bands that have created a narrow mesentery in order to broaden it as much as possible. Sometimes there are also LADS bands that cause obstruction of the duodenum and so you want to make sure that you free up and straighten the duodenum to avoid concerns for feeding intolerance related to duodenal obstruction. And in this part of the surgery a lot of surgeons choose to do an appendectomy. The real driver for taking out the appendix is just knowing that it's going to be in an abnormal anatomic position and if you leave it in place you have to remember to tell families that if they present with signs they need to tell people that their appendix is not in the normal location that the kid is not rotated. And then after you do that you're going to put the bowel back into the abdomen in a non-rotation configuration. It's a small bowel on the right, large bowel on the left as a way to the intestines and try to keep that mesentery as broad as possible. We know a significant amount of debate as to whether or not a laparoscopic LADS procedure is a good procedure or not a good procedure. And Dr. Carter Gall says it depends a little bit on your theory of why you think a LADS works. Some people believe that part of the benefit of doing a LADS procedure is A you widen the mesentery. But you also cause other scar tissue helping to the bowel to scar at a conformation that prevents midgut valvulus. So if you're doing a laparoscopic procedure you have decreased rates of adhesions related to that it's possible that you might not get that adhesive benefit. That being said one of the other downsides to doing a LADS procedure is the high rate of intestinal obstruction. So about a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure. And so the thought is maybe that doing it laparoscopically reduces that risk of postoperative bowel obstruction. So it's a balance. What I often will do is if I'm concerned in an older child, not a kid who's presenting with midgut valvulus but a kid who has symptomatic malrotation, I might start laparoscopically and determine whether or not I think the mesentery is broad or very narrow and then look at the duodenum. If I think the mesentery is actually fairly broad but the biggest problem is bands around the duodenum causing obstruction, I might do that laparoscopically. For cases where the mesentery is very narrow, sometimes Dr. Cartergaul thinks that's a harder procedure to do laparoscopically. There's some controversy about whether you can successfully broaden the mesentery as wide as it should be by a laparoscopic approach. There is some controversy as to whether or not you should or should not do a prophylactic LADS. In a kid with diagnosed malrotation or kids like congenital diaphragmatic hernias who we know by definition have malrotation because of the long-term risks of bowel obstruction and the complications that can result from that. In general, in younger kids when they present with malrotation their likelihood or risk for volvulus is higher or for symptomatic malrotation is higher and so we tend to fix them or do a LADS procedure more commonly in young kids. But again those are opportunities to really have good informed consent discussions with families around the risks of both doing or not doing the operation and what they might prefer and particularly access to care. For families that are much more remote they might opt for an operation accepting the risk for bowel obstruction knowing that in the event of an acute volvulus they would have a much harder time getting to the hospital in a timely fashion. That was all regarding the diagnosis and treatment of malrotation. In this podcast we reviewed using upper GI for malrotation diagnosis by looking at the position in the course of the duodenum in order to determine whether or not it is normally or abnormally positioned. Also we talked about surgical treatment of volvulus which is going to the operating room and doing an exploratory laparotomy. Also mention some controversial topics like using laparoscopy for LADS procedure or if prophylactic LADS procedure is necessary in an asymptomatic child. Thank you for listening to this podcast. 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