Oops, I've had a little technical failure here. I can do it for you. So I'll advance your slides for you. OK, we'll get the screen there. OK, um, so when, as we're going along with this talk, there's, um, I want to stick to sort of the more complex and subtle, uh, controversies within malrotation, and I would like the audience to think about the classification of malrotation. Can we really do it? And if we can do that, can we stratify risk based on this classification of the different types of anatomic malrotation and then can we stratify risk by other factors such as age and would it change what your management would be. So, the first case is a teenager who presents to an outside emergency department with transient abdominal pain and non-bilous emesis that occurred two weeks ago. He ate food at a picnic and several guests at the picnic became ill. He had a CT scan done at an outside emergency room, which was negative for appendicitis, but was concerning for malrotation without valvulus. Uh, the patient was sent home from that emergency room and presents as an outpatient for follow-up. Uh, there's no other history of GI symptoms previously, and upper GI is obtained. And so advance the slot. There we go, it just started to work. I got it. OK, so, um, so first let's, let's look at this, this image and I guess we could pull some people in the audience. Why don't we start with, with Todd, um, if you're going to classify this kind of malrotation as a typical, atypical, non-rotation. This is a complete non-rotation. Complete. Is anybody else in the audience have a fixed rotation? Yeah, I think I wouldn't want to commit myself until I saw where the cecum is because I think the key point is what's the distance between the ligament of trites and the ileocecal junction, but I'm guessing based on this that it's likely going to be non-rotation, and I wouldn't do anything about that. OK. And the, uh, the other thing is, uh, if you want to ask that question about the cecum, how, how would you? Uh, go about assessing that. Usually, uh, we just do a follow through and, uh, and then sometimes you, you can't reliably see where the cecum is and they have to do a contrast. OK, sounds good. Oops. So I'll go back. So what, what is the, what is the best approach? So your choices are, first, uh, laparoscopy and possible LADDS procedure, uh, a laparotomy and open lads procedure. Uh, discussion of the risks of volvulus with postoperative bowels, uh, uh, of, of, uh, volvulus versus postoperative bowel obstruction following lad's procedure and then let the parents decide or, uh, observe this patient with non-rotation or obtain further imaging like an ultrasound and perhaps we should add to that a, a contrast enema. So, Jonah, you'll put that pole up. Let's fly through the room here. So, um, I'll start. I would do, I would do laparoscopy, um, Jack, I know what your answer is, but I would do laparoscopy, um, to evaluate, um, for lads, bands, and anything that may be causing an obstruction and try and make sure it's completely, the mesentery is completely separated. So I would do the appendix. What's that? Yes, I'd take out the appendix. So you do a labs. I do a labs, yeah, except he's already had a lads. I knew that's what my, that's why I was specifically saying what I would do because the patient has already had a lads, but not necessarily. I mean, this mesentery might not be completely separated. There still might be lads bands that need to be divided to both free up the duodenum and also to get good separation for the cecum to be completely opposite. I don't know until I go in and look, um, on this patient, but. But you can follow him clinically. I, I think the key. The key reason to operate on what we're going to call an asymptomatic patient or maybe minimally symptomatic patient is to avoid a midgut volvulus, right? Lads' bands do not cause midgut volvulus. So if they do, if they're, they do if they're shortening the mesentery. Well, I would say it the other way around. I think you get lads bands if you have a shortened mesentery. I don't think the lads bands cause shortening of the mesentery. By dividing that tissue that is that when you go in and divide that tissue and the mesentery splays out. So the lads bands are not right, but there's continuation that goes right along the mesentery. So there's the bands that going, going on top of the duodenum that would free up a duodenal obstruction, which I agree is not dangerous, but this kid's been vomiting, but it was only one episode. Um, but I, I would want to see that that tissue that's that filmy tissue that's on top of the mesentery that if you divide would splay it out and also divide that anterior leaf would give you a wider mesentery than than the way it is now. Well, I guess the question is, what distance do you need the ligaments and the ileocecal junction to prevent, to prevent volvulus, and nobody knows the answer to that. Well, I would do 3 and then when the family asked me what I would suggest, I would suggest 1. So I think That's actually a great answer. I, I think that's actually, well, I think you need to explain to them why, you know, the risk of the, of the volvulus. I think the risks are quite low. And on the other hand, I do actually believe if you do a laparoscopic bladder procedure, you reduce those risks. You never reduce them to zero. but I think the child's going to live, you know, hopefully, you know, 60, 70 years, and, And I certainly know adult surgical colleagues who've had to operate on mid mid-gutboulus and 30-year-olds and 20-year-olds and 40-year-olds. So to me it's a lifelong concern, uh, and whereas you don't reduce, you don't make take the risk to zero, you reduce the risk, and so it ends up usually that you do one. Well, I agree with the conversation with the family ahead of time. This particular one, you see the small bowel pretty well on, but a lot of these kids, you don't see the small bowel light up, and I don't really know that they don't have a vulus. So, I have to admit I, I sometimes get 5. I do an ultrasound and I look and see where my SMA and SMV is. I look and see if they have a whirlpool around it. And, and if they have signs that they might have ovulus, I might not go laparoscopically, um. If I didn't have a volvulus, I'd probably just do a scope and, and see if I could make things better. I think I would scope. I, I, I have recommended the endoscopy. I've only had one patient after that very long and detailed discussion. Uh, say they'd rather not have surgery and they'd rather just be watched and etc. but, uh, I would, I would recommend, uh, laparoscopy. I think it may maybe I'm treating myself, but, so before we get to John, I just want to clarify something about the poll results here. Nobody said laparotomy with open labs, and I think it's the way the question was phrased because the first one says laparoscopy and possible labs. I bet you there's some people out there that would do laparoscopy and the possible labs would be open. Uh, I'm not sure that that means in laparoscopic labs, so that might be that group. Sounds like most people would at least put a scope in. I'm not sure if that audience would also then go then do a laparoscopic labs or do an open labs. Well, I left it open purposefully, depending upon what your opinion would be, because some people say, uh, you know, the laparoscopy is just for diagnosis, but I don't feel comfortable doing the labs, right? And I think that's not pulled out in this data, so we can't quite say for sure, John. Um, I think this is extremely difficult because I think the hardest part for the laparoscopic labs is really dealing with the mesentery in the bowel. I think the laparoscopy is very good for dividing, freeing up the duodenum to obviously taking out the appendix. So, um, I might watch this patient if I had the right family, uh, assuming the cecum was pretty far away from the, uh, presumed ligament it's right, so where I, I felt reassured that the mesenteric was broad. Dan, I'd be in the laparoscopy group for a laparoscopic for both, for both identification and treatment. I'd be in the laparoscopic group. Again, I, I, I don't know what study can tell you to do something differently. I think you can do a very, very effective laparoscopic labs, even in a newborn. So ovulus? Yes. Well, I have done ovulus in a newborn, but if it's too twisted, you can't, you don't have any room. Right. So you have to just base, based on how it chopsticks. What kind of room you have. Yeah, I would do laparoscopy. I would offer laparoscopy. OK, I bet you Barry Gibb wished he had laparoscopy. So what I, I would also do is what Wit said 3 and then 1. But one thing I would do is let's say if you let the, if you talk to the parents about it and they decide, no, no, no, I, I don't want this risk of small bowel obstruction after a possible lads procedure, I'm anxious about it. I might do another study to see where that fecal position is because if I know that that fecal position is, if I think that the mesentery is wide, I either they're completely non-rotated, some people would, would uh put a scope in and say, oh, they're completely non-rotated, their mesentery covers more than half of the abdominal width. Definitely don't need to do to do anything there, so I would feel more comfortable saying you don't need to do anything, whereas if the cecum is more towards the midline and you think that it's fused, uh, with the small bowel, you might have a narrow or mesentery, so I might push them a little bit more, but that's back to where the, the risk stratification is not very good, it's not absolute, but there are subtle points. OK, let's do the next case. So, we're going to make it a little bit more complicated. So, in the second case, you were consulted for a gastrostomy tube in an infant with feeding difficulties. This is a 3 month old, 37 week gestational age infant with hypoplastic left heart syndrome who's had the first stage of correction. They weigh about, kilograms. The child has a few non bilious spit ups, but a very poor suck. He tires easily and does not eat well. He had a really rocky postoperative cardiac surgery course with a long, uh, ICU stay. He's getting ready to go home and he's on some nasal cannula oxygen. An upper GI is ordered in the course of his evaluation either for screening or because of his spit-ups and it reveals a low lying ligament of trites with possible malrotation. This family, unfortunately, lives in a semi-rural area and the nearest children's hospital is 3 hours from their home. The upper GI that's obtained demonstrates this. So I was, I was going to ask uh members of the audience, Pete, how would you, uh, um, oops, how would you classify this upper GI with the ligament, with respect to the ligament of trites? Typical, atypical, high, low lying. Well, for us, it's a typical, cannot rule out malrotation scenario from our radiologists. Um, it's a, it's a, technically, it's a low, low lying, uh, ligamenttrites may or may not be associated with malrotation or non-rotation. It's uh, the classic dilemma for us, I think, uh, in terms of, uh, what to do. Now, this is a patient. He's being worked up for, for having a G tube. So I might not have done the upper GI at all. That's what I wanted to hear you say. I, I usually don't, uh, but oftentimes they get it done, especially if they're in the NICU. But, um, so I would say, well, we're going to do a lap G tube anyway, maybe we can just sort that out while we're there. OK. And I'll show you the lateral view because maybe that, that will help you as well. That's his, uh, his upper GI. So, can you go back to look at the, go back at the previous x-ray. I just want to point out something. You see how dilated those loops of bowel are? So, that, that's going to always give you a low lying ligament of trites when you have dilated loops of bowel. And that's exactly why I don't get upper GIs when you're just ruling out for a G tube. If it's, if it's a patient that has vomiting, excessive vomiting, and working for a Nissan, I think that's a different case, although Sean says he doesn't even get upper GI's necessarily for those patients. But this is an example of, of something that I would repeat the x-ray on. Um-hum. Um, after, or repeat the upper GI after this episode is, has resolved. Right. Um, you, you could also, uh, complicate this. You wouldn't get upper GI, but let's say the patient has a heterotaxi syndrome. So, many of your cardiologists are going to routinely screen, screen them for IRA, so, intestinal rotational anomalies. So, uh, so you may not have a choice. OK. So, what's the best approach for this patient? Would you, number, oops sorry, numbers all change, but would you place an endoscopic primary button, 12, would you proceed with an open LDS procedure and do a G tube at the same time? Would you, 3, do a laparoscopic evaluation, possible laparoscopic LDDS procedure and lap G tube? Would you, oh, sorry. Would you place them, because the child has a very, is a tenuous child, they, they're on oxygen. They didn't do very well. Would you place a nasogastric feeding tube and observe this indefinitely because you thought this was a low-risk situation? Would you place an NG tube and observe until their cardiac status is better, i.e., they've had a three-stage reconstruction of the heart disease, and then proceed with the LDS procedure in a G tube, or would you get a contrast enema to figure out the position of the cecum to help you decide what to do. And this child who lives in a rural area and is not a very good health risk. A little bit subtle. So the, the, the results are going to keep changing because they're refreshing, but right now it looks like the majority of people would do a laparoscopic evaluation, possible lab, uh, lab labs procedure and G tube, that was for the, for the, uh, Last one. And hope, hope he tolerates the lab. Yeah, I think that in our place, our anesthesiologist, I'm not sure they'd let us do a, a laparoscopic operation, at least a prolonged one, because of the child's cardiac status. Uh, we might be able to do a lap gastrostomy, uh, but I'm not sure we'd be able to do the. You know, a malrotation that, that's anyway, it's a concern at our place from anesthesia. So I, so if I looked in there and the kid was not malrotation, low, low lying ligament, G tube, I'd probably do a Nissan on the kid too, lap Nissan. Oh. So, this kid's probably between his first stage from his Fontana and his Glen. They're not getting out of the hospital. So we do, we do Nissans on most of those kids. They actually ask them, ask us for them because they'll get a G tube and they'll vomit and they're too, too small for pegs. And if you do a 45 minute niss and pressures of 8, they tolerate it. So the only person I know that what's that 5 kg too small for peg. Peg, I don't do pegs, but I do, but I don't think so. No, but I think the only person I know that likes doing this ones more than Rothenberg is Tim Kaine. Um, and, uh, I don't think there's any data to support that, Tim. We, we actually just published our experience with, with combined with Kansas City that that risk group did not stratify out to be at higher risk for reflux, uh, for having reflux complications. Um, it was the, the neurologically impaired CP kids maybe, but the cardiac kids did not stratify out to be at a higher risk. So I, I don't agree with that. I, I've seen those kids go home and aspirate with just G tubes, so that's that's why that we would consider that's not up there is actually place an NJ feeding tube. Laparoscopically? No, no, just a nasal. So, and, and, and I actually strongly agree with that. There, there is, um, uh, that, so this is a tenuous patient and placing a, a feeding tube and then waiting till they're healthier to do anything or make a decision might, might be actually the most prudent thing. There's, uh, actually a fairly high risk of complication, at least in the patients with heterotaxia syndromes who have asymptomatic malrotations who get operations, remarkably high. It's between 30 and 50% of patients have a major complication associated, uh, with that. The other subtle question again, is I said, think about, um, classifying it. This is a, a, uh, I would classify this if we go back on 11 image as an atypical malrotation with a low lying ligament of trites, and there is some data out there that those patients actually have a lower risk of valvulus. It's not really strong, but it, it, there is some there. So now we have the exact same patient, but you I just you know, the, the basic principle is what's the distance between the ligament or trites and the ileocecal junction. So, you, you don't know that information in, in that. So you really need to visualize the cecum. And then make your decision. If the cecum is in the right lower quadrant, probably this is not malrotation at all. This is probably not a rotation abnormality. This is probably just those dilated bowel loops pushing the, pushing the duodenum down. And, and then it's a matter of, you know, are you gonna operate and put in a G tube? Are you gonna do an NJ? We, we would probably, if the anesthetists would allow us, we would do a, uh, a GJ tube, the radiologist placed them for us. OK, now you have the same patient, uh, exact same clinical scenario, but the upper GI is different. Uh, you see the small bowel to the right of the spine. So, in this patient, what would you do? Would you do 1, an open L LDS procedure and a G tube placement, uh, 2, a laparoscopic LDDS procedure and a lap G tube, 3, Uh, place a nasogastric or nasojujunal feeding tube and observe indefinitely, uh, and 4, place a nasal, a nasogastric or naso jejunal feeding tube and observe until the cardiac status is more stable, and then come back and do your labs procedure or G tube, and we'll add choice number 5, get, get a contrast enema and see where their cecum is. I think for this case, it's, you know, you, you can tell that they're clearly malrotated. So, it's much less useful there. Todd, what do you think? I'm reading some of these comments here from Yama, uh. Yama's saying to, to, yeah, glasses to diagnose malrotation you need a lot of contrast medium in the proximal small bowel, um. Yama also says, Um, to look at the SMA and the SM SMV, I think ultrasound. And then, uh, Gloria Gonzalez says, got it. Do you think there's any image that would help you know the width of the mesentery? Because you talked about the width of the mesentery. Uh, how good is that SQL evaluation for looking at the width? Well, I think when it's close to normal or it's close to total non-rotation, I think it's pretty good. I think it's pretty valuable. If in those in-between ones, I'm very liberal about putting a scope in and, and looking at it with the with the scope. So, one key point of that is that if you look, one of the reasons that we don't use. Uh, barium contrast enemas to determine whether someone has malrotation is in 20% of cases with true malrotations of the fore and mid-gut, you have a normal barium enema. So, it really in this case, the upper GI is really the, the key point, so I don't think it's relevant to this. The other thing that's important about the, uh, we have it in a mock question, but a, a normal ultrasound does not rule out a vulus, and there's a couple of studies that show that. Alright, so anybody else have any strong opinions? What would, what he's not on the phone, but he's, um, he can, we can get him on the phone. For a lifeline. Yama, we want to hear what you do in Japan. Get on the phone and call us, um. So, I mean, I, I think that I'm pretty aggressive with the, the laparoscopy and the lap labs, even in the, in the tenuous patient who, who is on oxygen and really not doing very well after their first operation. Right? I don't think that there's, uh, Right, I mean, it, it, it, I guess you got to take what's that no but no answer, OK. We'll get, we'll get him on the phone. Um, uh, each case comes in a different situation. That's why I also want to ask Tim about the Nissan in that patient too. Um, would you wait, you know, until they were more stable or do an open Nissan in that kid? Oh, what's that? So what, what I'm saying is if you start putting the laparoscope in and they tell you they can't tolerate it. Um, in that case, I, I think if it's that unstable, I'm not going to do an open because that's what we're talking about, right? This very unstable patient, I would not do an openness and, um, or even the lads, right at this point you would wait, yeah, yeah, yeah, and if it's that just low lying ligament, everything's normal, then you could perceive it certainly. But in this third case we know they're mal rotated because that upper GI, are you there? Yeah, yeah, what I would ask, what is the color of aspiration through the nos gastric tube? That is crucial. If that is green or slightly green, I think the patient needs, uh, you know, operations. Even though the contrast goes through when I saw the contrast study, I was not sure the patient has a malrotation or not because you know a small amount of contrast medium in the small bowel. That's why I wrote more contrast, OK. Yeah, we need, we need a lot of contrast medium in the proximal bowel to diagnose bow rotation precisely. That is crucial. Yama, what if we're gonna, I'm going to read the poll answers in a second here, but Yama, what if it was yellow stuff in the aspirate? Is that bile yellow stuff, even, uh, you know, even that is a, that is a caution. It's. It's like a traffic. I want to repeat, I want to repeat the contrast studies to diagnose malrotation because if you can go ahead and do the laparoscopy, but if you found If you find nothing, what would you do? That is a waste of time. If you find nothing, meaning what? If you find no volvulus, it's normal. Well you know you cannot find, you cannot find any ligament. You also find the, you know, pedicle. Yeah. What would you do? Well, that's back to the first question. So now we have non-rotation. So, uh, one of the biblio, one of the references the bibliography is one of Dr. Langer's papers. So don't trust it. So. If, uh, you know, complete non-rotation, uh, where the small bowel is on the right and the cecum is on the left, you would just, uh, observe it, put the scope in and say, oh, he's, he is, he's had already a complete lads from Mother Nature and do nothing. But I think that's raises any question because to me the answer is whether to do an operation or not to do an operation as opposed to doing a laparoscopy and then not doing an operation. So I think most of us would, if you can do the laparoscopy, you might as well do the lab procedure. But, but, but with that doesn't make sense if they're non-rotated because the lab procedure puts them into non-rotation. You can't, you can't do a lab procedure on somebody who is non-rotated already. Do you take their appendix out? Well, I do if I'm in there already, but I wouldn't go in just to take out their appendix. Yeah, so, anyway, I, I actually worry about the, uh, width of the, the mesentery issue. So, if I'm going to do a laparoscopy, I'm going to evaluate that and likely you're going to find something that it's not that wide and you can widen it out, so you're going to do something. So, I would, to me, the issue is whether to operate and do something, do anything or not to operate. Uh, that's right, and I think that's the reason I picked this structure this case that way is because this is really a very poor risk, uh, surgical patient. Well, you're very high risk of surgical complications. OK, but I, I do think you've raised a question because we have looked at this issue too, that there is actually a fair amount of morbidity in this particular patient population that, that, that we may not be reading because at least when we looked at the literature, it was in the cardiology literature as much or more than it was in the surgical literature. So, so there are some recent papers. There's a paper from Edmonton from where they, uh, um, Uh, did these procedures and on patients with heterotaxis and, and had them, and their, their complication rate was about 50%. It's very, very high because they're just basically poor risk patients to begin with at high rates of bowel obstructions and there's an, uh, there's another paper just published in the last year by Papillon from, uh, Children's of LA where they looked at a large group of heterotaxy patients, about 200 patients, uh, and, uh, they got about a quarter of The they got upper GIs for screening that were done just looking for rotational anomalies, and the other, uh, three quarters, they did nothing and in 4 years, they only had one case of volvulus, and in the patients who did not have bio emesis and, and symptoms, no cases of volvulus. Yeah, and we published the same, exactly the same thing about 10 years ago. So, it, so it's, uh, so it's actually, at least in that heterotaxy subgroup, um, the risk of volvulus in the early, Uh, period, i.e., 4 or 5 years, is actually very low if they're not symptomatic. OK. OK, so, next case, we have a 16 month old male toddler with, uh, frequent but non-bilious emesis. This child eats well. He, he has an upper GI that's reported as having redundant duodenum and the location of the duodenal junction is unclear whether it rises to the level of pyloris, um, and a small bowel follow-through is also performed. This child has no symptoms of abdominal pain or other GI symptoms. So here's his, here's his lateral view if that helps you. I don't think it's particularly uh uh view is particularly important. I also think, um, do you think, uh, as far, uh, I can ask John Crow, do you think the age of the child matters? I was gonna say I, I've had quite a few of the heart patients who have these weird, uh, abnormally low ligamenta trites and I follow them and see how they do. Some of them, when they get weaned from milk to food, seem to become symptomatic, assuming the cecum's in a good position and the mesentery is wide. So, um, I certainly think that this child, even though he's throwing up a lot, I'd follow. I don't know that if I, if the cecums were in the right lower quadrant, I wouldn't rush ahead to operate. So, so the data, data on that is in the first two months of life, about 7, 70% of volvula occur in that time period, and by the first two years of life, 90% of volvules, the volvuluses that are going to occur, do occur. So I actually think age does matter. In the first case we had with the A 15 year old teenager, you know, they've had a little bit of a test of time. The problem is that that's not an absolute, but that, that's what makes our life difficult. So here's his small bowel follow-through, and this one they actually did the small bowel follow-through, and, uh, Todd, what do you see? I was going to say yama, is that enough contrast for you? That's good, you know, comes up by the throat. OK. So, what do you see? Well, the cecum is up by the, up very high. So, on the right side, high rising. Yeah. So, I mean, that's, this is pretty impressive to me that this patient has true malrotation. OK, and we'll look at his upper, upper GI again. So, he's got, I don't know, I look at this, I say maybe this is a low lying ligament of trites, maybe. Yeah, but, yeah, but it's more important that there's the redundant, the redundant duodenum there. Right. Yeah. So this is a patient that I would. So what do you do? Oh, so can I just tell you that I wouldn't have gotten the contrast enema because I would have put a laparoscope in. He, they did a small bowel follow through here very convenient. They did a bowel follow through in this patient. So remember that the patient is coming to you for vomiting, that he really has a lot of non-bilious emesis. So what would you do for this? I'll ask Dr. Kane what he would do. Would you evaluate further for reflux with a pH probe, uh, A nuclear medicine reflux study and GES study, um, would you do an open L LDDS procedure on this patient? Would you do laparoscopy and do a possible LDS if his mesentery is narrow, or would you do a lads procedure and a Nissan fundoplication, uh, on this vomiting patient with non-bio emesis? Yeah, I mean, I, it's pretty aggressive to do, you know, Uh, in a 16 month old presents to you, if you're worried about that actually, looking at maybe a low lying ligament of trites, I would do laparoscopy first, really look at the duoum, see if there's bands there, widen the mesenteric, and if, if there was some, you know, sign that there's, there's not much mesenteric, um, length, I'd just do that. I wouldn't do it in this at the same time, that's for sure. But I also probably wouldn't get more, you know, that's why I do do an upper GI in these kids because you just see, you can see any really, um. Obvious anatomic abnormality that you can deal with, but otherwise you're just guessing. You put a scope in there and, oh, what, what operation do I do next? So it gives me some information. So how are you going to solve his, let's say you put the scope in there. And his, uh, mesentery is wide, but his major problem is he really has a lot of non-bilious emesis. So, would you, would it be a benefit to get a preoperative studies, let's say a PH probe to look? Because my, my question gets at, you, you know, it doesn't solve your problem if you do a, a laparoscopy alone. Uh, you know, does this, I wonder if this patient is a patient who has really bad reflux. So. Right. And that's possible. So, if you're in there, Looking for malrotation, you don't find it, I think you need to back up and then get the studies because I, I wouldn't, again, do, do a big operation. Yeah, we have medicine for that. Yes, we're talking a lot about the lovulus, but what about the lads bands? How much of a role are those lads bands, partial duodenal obstruction, playing a role in the vomiting here and, and maybe just dividing those, you, you are done. So the question is, um, if you go in and there are And so my answer was I had a patient this exact situation and I talked to the parents ahead of time. I'm going to go in. Um, now your point about the meds throws me off a little bit. So that's a good point. Sorry about that. I'm not smart enough to think on the fly like that. So, no, but the, the, uh, patient, I said I'm going to go in. If I see evidence of a cause for this vomiting, such as impressive lads bands, um, evidence of a dilated duodenum, something that would tell me that there's some obstructive process, then I'll relieve it and that's it. But if I go in and I see No real cause for why this child would be vomiting, because I agree it's not going to be a volvios, this is gonna be lads bands, then I would go ahead and do a Nissan at that time, but I would have that discussion with them. Now, I will tell you that I don't see any need for any of those studies. I don't need it. The best study I know is the kid's puking his brains out, so I don't need a PH probe to tell me that this kid is vomiting. I don't need a milk scan to tell me that. In fact, you know my feeling on that. I think that none of those studies are very helpful, um, and so I go clinical scenario. So the question is, could I back out and try medical therapy? Well, so when, when did, when, when did the indication for surgery? Symptoms without a trial of medical management and with no complications of the disease. So that's a great point. Uh, the kid that I had in my patient was losing weight. OK, so that's an indication for surgery for me. It is, but even without a trial. That's what I said that so I suppose you could say, OK, you're, you know, then, then the question is you'd have to trial it, you'd have to do an operation trial and then go back and operate again instead of trial first, instead of trial first with medical therapy. So I suppose, um, that That's probably a good option, but I don't have a problem. That would be the only reason potentially is to see a medical therapy, but this child needs to be treated for reflux, whether it's medical therapy or surgery. It's very interesting. I'm looking at the poll results and the, and the audience, 61%, by far the largest percentage, says evaluate further for reflux. So my guess is that they're thinking that. The question of malrotation here is really an incidental, but again, it doesn't help us here because whether you evaluate for reflux or you go based on the fact that he's vomiting, you still get to Jack's point is that, OK, he's got reflux. We know he's got reflux, the kid's vomiting all the time. So we know he's got reflux. The question is, do you go to make sure it's not an obstructive process, back out, try medical therapy, and then go back and do a Nissan if the medical therapy doesn't work, or do you just go do an upfront Nissan since you're in there? So, that's a, uh, uh, I may retract my thought based on what you said. So, that's a good point. I would do the labs first divide those bands and see what I get. And if it, and if he was still refluxing, then I'd put him on medication, and if that failed, then I'd re-operate on him. So, I think this is my patient, I think, and I did a labs, and he's still throwing up. There you go. I could, looks like that. Did you try meds? Did you try meds? No, no, I just thought he had a classic malrotation the way they read it after your lab procedure failed. This is your patient. Oh, he's in the hospital right now actually. So. So Yama, what are your thoughts? I, I, I, you know, the patient is gaining weight, correct? Gaining weight, correct? Patient's OK, this kid was throwing up. Yeah, so I, I, I don't do anything. Because the patient is fine, gaining weight and clinically well. Why do I have to operate? Did you do the labs or no? No, I don't do it. I don't do first observations because gaining weight and eating well. And the only symptom is vomiting, correct? Yes, but he's got malrotation. Yeah, but aspiration of the energy tube is non bilious. So not dangerous. OK, Gama. So the kid, so you wait, I want a question because I want to understand because one of the smartest guys I know. So I want to make sure I understand. So you take this patient, he's, he's, you, you observe him, and let's say his vomiting for the next couple of weeks gets better. You're not going to operate on him? Uh, as far as the, uh, you know, the patient is, uh, uh, you know, nonbi. You know, the patient does not have bilious vomiting. No, no bilious vomiting, no bilious vomiting, asymptomatic, and I don't, I don't operate. On any, on any patient that has. When, when the, when the patient becomes symptomatic, probably I will do ultrasound and the contrast medium, whether the patient has, you know, valvula. OK, so you don't operate on, you don't operate on asymptomatic malrotation. Asymptomatic one, no. You know, as far as the patient has asymptomatic, as far as the patient has non bilious vomiting, I, I don't operate. If the patient is gaining weight, if the patient is clinically well. OK. Check. Oh, I, I operate on malrotation or even suspected malrotation. If there's any chance in my mind that there could be, uh, a narrow mesentery, whether there's bilious vomiting or anything, I, I will put a laparoscope in. So, Yama, I guess the, the general consensus in the studio here is that not talking about non-rotation, but malrotation. Yeah, go ahead. But I feel if the patient has a narrow pedicle, the patient always has vomiting and symptomatic. But they might have, OK. But they have a risk of rotating at some point in their life, even if they're asymptomatic now, #1. #2, they may have lads bands that are causing a problem even if they don't have a widened mes neuros. Personally, personally, I don't think lap bands cause the valvulus. It can cause compression of the duoden, but that band itself is not risky. The risk is bilious vomiting and the narrowing of the pedicle. That needs operation. OK, so you will not operate on a patient with malrotation unless they have bilious vomiting. No, I don't think so. As far as the patient is asymptomatic. OK. We can wait. You know, on this particular patient, since the cecum's high riding, as I recall. Yes. Yes. It's more likely, I think, to have obstructive or significant land spans than it is to be in a patient if the cecum somewhere else. Uh, because lap bands are thought teleologically to be an attempt of the body to fuse the cecum to the, you know, lateral peritoneal wall, and so you, you fuse it, uh, up in the right upper quadrant and obstruct the duodenum. Uh, so, uh, in this particular scenario, it's not unreasonable, I don't think, to do a laparoscopy, divide the bands, uh, and see if the symptoms improve or not, and then, and then proceed, uh, accordingly after that. OK. However, I'm being told by the back studio that we're way over. So, let's do rapid fire, just Q and A and, and no discussion. Just, OK, well, we can do one more case. Yeah. 12 year old boy who comes to the ED with a transient right lower quadrant pain, Diarrhea and emesis, no other symptoms. He gets a CT scan that's concerning for malrotation and situs, but otherwise normal. He gets sent home with a diagnosis of gastroenteritis and comes to your office, uh, uh, 4 weeks later as an outpatient. You get an upper GI and his cardiac, uh, evaluation is normal. You have this CT, stomach is in the right side of the abdomen. Liver is right sided to midline perhaps. Here's his upper GI, right sided stomach, contrast goes transversely across the abdominal wall, and here's his lateral view. So, I'll show you these 22 again. Here's the AP, and here's the lateral. What do you do for this patient? Do you do an open labs procedure, laparoscopy, and possible labs, or observe the patient and counsel the family? The quick quick patient with situs ambiguous or situs inversus, what do you do with them? I have struggled with these. I laparoscopically have great difficulty figuring out malrotation in patients with sitis, and I can't think of any that I've successfully completed lab, I, I mean, end of three, but, uh, I've had to convert them all to open. I don't mind sticking a scope in there and maybe the 4th time I'll get lucky, but man, it's, it's tough to figure out your orientation. But it almost doesn't matter because if you go back to the basic principle of what's the distance between the ligamatrites and the ileocecal junction, you can measure that distance no matter where all the bowels are and if it, and I just arbitrarily use half the diameter of the abdominal cavity, if it's less than that, then I do whatever I need to to try and separate them, and if it's not, then I just stop. We're actually, I, I would operate. We're actually you're a lab, yeah, I, I would agree with that, but this is a patient I, I'd probably maybe observed, having done a laps on a kid with sits and versus, really difficult, but, um, it's, uh, you know, this kid I might observe because the chances are everything is as it should be. But if you put a scope in, you can, you can again assess the mesenteric just with like Jack says, we just did one and we're presenting it at the college, um, but it's a laparoscopic labs in aciis and it was. I could not get my brain around it like you said, but we did it and we saw really engorged uh vessels right around the area, which was interesting obstruction venous obstruction. And so it was a very impressive case, but it really, I kept The Yama would have picked that up on the ultrasound, right? Let me, let me actually, before we finish because we're going to have to stop, but I do want to address something that's been mentioned a few times and there's a question from the audience about the significance of the mesenteric vessels, uh, being, um, reversed. What is the significance of that? I don't think you see that with malrotation. It's more with volvulus, and that's the important point that I wanted to, that's true. You see, you see it with malt with any rotation abnormality. You are, you may see that. You may not see that. I see. So you can, so seeing, I see, so. It doesn't help us then because it only helps according to the according to our according to our data which because we had several 100 patients, there was never a case where the vessels were normal. In a patient who had a risk for valvulus, a narrow base mesenter, so we use it as a screening test in patients who are really sick. They've got peritonitis. You, you wanna make sure that it's not mid gut valvulus. If you do an ultrasound and you see normal orientation, at least in our experience in our series, there was never a case where it was v because that's different from some of the other literature says that you can have a normal ultrasound and be volvulized, and that's why. Uh, it's not as reliable as your upper GI series. The upper GI is clearly better, but in a sick patient that you can't get down to radiology, you can't do. That's interesting. And for me, when it's that, that low lying, that indeterminate, or they're not well enough to go down to radiology and put all that contrast in there and see the cecum, uh, you know, that's, that's when I have used ultrasound. All right, well, we're gonna, um, that was fantastic. We're way over, but that's my fault. So we are going to take a brief break. Please, again, I'm begging you, go to the exhibit hall, check out the stuff that's in there. Uh, there's 2 exhibit halls, go to both of them. Please stop by and say hello and thank the booth staff for, uh, for helping support the show today. We'll see you in about 10 minutes.
