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Impact of bowel rotation and fixation on obstructive complications in congenital diaphragmatic hernia

      Highlights

      • Malrotation and nonfixation are associated with increased small bowel obstruction (SBO).
      • Normal rotation is not fully protective from volvulus.
      • Malrotation without LADD procedure may increase risk for SBO including volvulus.
      • Bowel rotation and fixation should be evaluated during initial surgery, routinely documented and used for family counseling.

      Abstract

      Aim of the study

      Small bowel obstruction (SBO) is a known complication after congenital diaphragmatic hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor for SBO including volvulus.

      Methods

      A retrospective review of 256 CDH survivors following repair from 2003 to 2020 was performed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvulus. For statistical analysis Fisher's exact test was utilized.

      Results

      Twenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%).

      Conclusions

      Malrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical intervention is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely documented and education about the risk of SBO should be included in family counseling.

      Level of Evidence

      Level IV – Case Series

      Keywords

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      References

        • Harting M.T.
        • Lally K.P.
        The congenital diaphragmatic hernia study group registry update.
        Semin Fetal Neonatal Med. 2014; 19: 370-375
        • Kays D.W.
        • Islam S.
        • Larson S.D.
        • et al.
        Long-term maturation of congenital diaphragmatic hernia treatment results toward development of a severity-specific treatment algorithm.
        Ann Surg. 2013; 258: 638-646
        • Putnam L.R.
        • Harting M.T.
        • Tsao K.
        • et al.
        Congenital diaphragmatic hernia defect size and infant morbidity at discharge.
        Pediatrics. 2016; 138e20162043
        • Safavia A.
        • Synnesb A.R.
        • O'Brienc K.
        • et al.
        Multi-institutional follow-up of patients with congenital diaphragmatic hernia reveals severe disability and variations in practice.
        J Pediatr Surg. 2012; 47: 836-841
        • Betremieux P.
        • Lionnais S.
        • Beuchee A.
        • et al.
        Perinatal management and outcome of prenatally diagnosed congenital diaphragmatic hernia: a 1995–2000 series in Rennes University Hospital.
        Prenat Diagn. 2002; 22: 988-994
        • Jancelewicz T.
        • Chiang M.
        • Oliveira C.
        • et al.
        Late surgical outcomes among congenital diaphragmatic hernia (CDH) patients: why long-term follow-up with surgeons is recommended.
        J Pediatr Surg. 2013; 48: 935-941
        • Colvin J.
        • Bower C.
        • Dickinson J.E.
        • et al.
        Outcomes of congenital diaphragmatic hernia: a population-based study in Western Australia.
        Pediatrics (Evanston). 2005; 116: 356-363
        • Bagolan P.
        • Morini F.
        Long-term follow up of infants with congenital diaphragmatic hernia.
        Semin Pediatr Surg. 2007; 16: 134-144
        • Khalil B.
        • Ba'ath M.E.
        • Aziz A.
        • et al.
        Intestinal rehabilitation and bowel reconstructive surgery: improved outcomes in children with short bowel syndrome.
        J Pediatr Gastroenterol Nutr. 2012; 54: 505-509
        • Baoquan Q.
        • Diez-Pedro J.A.
        • Tovar J.A.
        Intestinal rotation in experimental congenital diaphragmatic hernia.
        J Pediatr Surg. 1995; 30: 1457-1462
        • Heiwegen K.
        • de Blaauw I.
        • van Ling J.
        • et al.
        Malrotation in congenital diaphragmatic hernia: is it really a problem?.
        Eur J Pediatr Surg. 2020; 30: 434-439
        • Butterworth W.A.
        • Butterworth J.W.
        An adult presentation of midgut volvulus secondary to intestinal malrotation: a case report and literature review.
        Int J Surg Case Rep. 2018; 50: 46-49
        • Sizemor A.W.
        • Rabbani K.Z.
        • Ladd A.
        • et al.
        Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation.
        Pediatr Radiol. 2008; 38: 518-528
        • Lally J.P.
        • Lasky R.E.
        • Lally P.A.
        • et al.
        Standardized reporting for congenital diaphragmatic hernia – an international consensus.
        J Pediat Surg. 2013; 48: 2408-2415
        • Applegate K.E.
        Evidence-based diagnosis of malrotation and volvulus.
        Pediatr Radiol. 2009; 39: 161-163
        • Levin T.L.
        • Liebling M.S.
        • Ruzal-Shapiro C.
        • et al.
        Midgut malfixation in patients with congenital diaphragmatic hernia: what is the risk of midgut volvulus?.
        Pediatr Radiol. 1995; 25: 259-261
        • Jancelewicz T.
        • Paton E.A.
        • Jones J.
        • et al.
        Risk-stratification enables accurate single-center outcomes assessment in congenital diaphragmatic hernia (CDH).
        J Pediatr Surg. 2019; 54: 932-936
        • Janssen S.
        • Heiwegen K.
        • van Rooij I.A.L.M.
        • et al.
        Factors related to long-term surgical morbidity in congenital diaphragmatic hernia survivors.
        J Pediatr Surg. 2018; 53: 508-512
        • St. Peter S.
        • Valusek P.A.
        • Tsa K.
        • et al.
        Abdominal complications related to type of repair for congenital diaphragmatic hernia.
        J Surg Res. 2007; 140: 234-236
        • Putnam L.R.
        • Tsao K.
        • Lally J.P.
        • et al.
        Minimally invasive vs open congenital diaphragmatic hernia repair: is there a superior approach?.
        J Am Coll Surg. 2017; 224: 416-422
        • Zani A.
        • Eaton S.
        • Puri P.
        • et al.
        International survey on the management of congenital diaphragmatic hernia.
        Eur J Pediatr Surg. 2016; 26: 38-46
        • Graziano K.
        • Islam S.
        • Dasgupta R.
        • et al.
        Asymptomatic malrotation: diagnosis and surgical management an American pediatric surgical association outcomes and evidence based practice committee systematic review.
        J Pediatr Surg. 2015; 0: 1783-1790