Intestinal Malrotation in Patients Undergoing Bariatric Surgery

Abstract

Background: Intestinal malrotation is a rare congenital anomaly. In adults is very difficult to recognize due to the lack of symptoms. Diagnosis is usually incidental during surgical procedures or at autopsy. Aim:To review the occurrence and recognition of uneventful intestinal malrotation discovered during regular cases of bariatric surgeries. Methods: Were retrospectively reviewed the medical registry of 20,000 cases undergoing bariatric surgery, from January 2002 to January 2016, looking for the occurrence of intestinal malrotation and consequences in the intraoperative technique and immediate evolution of the patients. Results: Five cases (0,025%) of intestinal malrotation were found. All of them were males, aging 45, 49, 37,52 and 39 years; BMI 35, 42, 49, 47 and 52 kg/m2, all of them with a past medical history of morbid obesity. The patient with BMI 35 kg/m2 suffered from type 2 diabetes also. All procedures were completed by laparoscopic approach, with no conversions. In one patient was not possible to move the jejunum to the upper abdomen in order to establish the gastrojejunostomy and a sleeve gastrectomy was performed. In another patient was not possible to fully recognize the anatomy due to bowel adhesions and a single anastomosis gastric bypass was preferred. No leaks or bleeding were identified. There were no perioperative complications. All patients were discharged 72 h after the procedure and no immediate 30-day complications were reported. Conclusion: Patients with malrotation can successfully undergo laparoscopic bariatric surgery. May be necessary changes in the surgical original strategy regarding the malrotation. Surgeons must check full abdominal anatomical condition prior to start the division of the stomach.

Laparoscopic Roux‐en‐Y gastric bypass in intestinal non‐rotation

“…Only a few descriptions of gastric bypass with intestinal malrotation are available and these are limited to clinical case reports 3 . Intestinal non‐rotation is a rare congenital anomaly resulting from incomplete gut rotation in embryonic development 2 . These rotation abnormalities may be presumed in adults as a result of ultrasound, upper gastrointestinal studies or computed tomography, although these investigations are not routinely performed before bariatric surgery 3 .…”

“…Intestinal malrotation is a rare congenital anomaly caused by a failure in normal rotation and a midgut fixation disorder in the fetal period, 2 which can remain totally asymptomatic until adulthood 3 . Non‐rotation is a type of malrotation that is usually without Laddʼs band and poses a lower risk of midgut volvulus owing to the wide mesentery 4,5 …”

“…In adults, intestinal malrotation/non‐rotation usually is discovered at the time of surgery and is a surgical challenge 2 . In this situation, the whole small bowel usually is seen in the right side of the abdomen and the colon and appendix are seen in the left side of the abdominal cavity 2,4 …”

Intestinal Malrotation and Appendicitis in Adults

“…The laparoscopic approach allows the exploration of entire abdominal cavity and diagnosis of the malrotation and of the type of malrotation, and the division of Ladd's bands and the treatment of the associated disorder (appendectomy, as in our case, colic, or bariatric surgery) [14][15][16][17].…”

Discordant intestinal malrotation in adult monozygotic twins discovered incidentally during laparoscopic gastric bypass: A case report and review of the literature

“…The first case involved an infant, and the second involved a 33-year-old female [2] , [3] . Vidal et al reported an incidence of incidentally diagnosed Malrotation of 0.025% in a study of 20,000 patients who underwent laparoscopic Roux-en-Y gastric bypass, none of whom were twins [5] . We present the first documented case of asymptomatic homozygous twins (A and B), who underwent LRYGB and had incidental discovery of isolated intestinal Malrotation made intraoperatively on twin B.…”