What is the treatment approach for an adult patient with intestinal malrotation?

Treatment of Adult Intestinal Malrotation

Adults with symptomatic intestinal malrotation should undergo surgical correction via the Ladd procedure, with laparoscopic approach preferred over open surgery when feasible, as it results in faster recovery, less narcotic use, and shorter hospital stays while maintaining equivalent symptom resolution. 1, 2

Surgical Indications and Timing

• All symptomatic adult patients with confirmed malrotation warrant surgical intervention, regardless of whether symptoms are acute or chronic 3, 2
• Surgery should not be delayed in symptomatic patients, as adults with malrotation experience diagnostic delays averaging 6 months or longer, leading to increased morbidity (60% complication rate) and reoperation rates (40%) compared to pediatric patients 4
• Asymptomatic malrotation discovered incidentally may be managed expectantly, though this represents a minority of adult cases 3

Diagnostic Approach Before Surgery

• Upper gastrointestinal contrast studies (UGI/SBFT) are the gold standard diagnostic test, correctly identifying malrotation in 100% of cases 2
• CT scanning has a 25% false-negative rate and should not be relied upon as the sole diagnostic modality 2
• MRI and angiography serve as alternative imaging when barium studies are contraindicated 1
• The diagnosis is frequently missed initially in adults—no adult patients in one series were correctly diagnosed at presentation, compared to 57% of pediatric patients 4

Surgical Technique: Laparoscopic vs Open Ladd Procedure

The laparoscopic Ladd procedure should be the first-line surgical approach for adults without acute midgut volvulus or peritonitis. 2

Components of the Ladd Procedure (Both Approaches)

• Division and release of Ladd's bands that cross the duodenum 1, 5
• Broadening of the mesenteric base to prevent future volvulus 1, 5
• Appendectomy (to prevent future diagnostic confusion) 1
• Placement of bowel in non-rotated position 3

Laparoscopic Approach Advantages

• Earlier resumption of oral intake (1.8 vs 2.7 days, p=0.092) 2
• Significantly reduced narcotic requirements on postoperative day 1 (4.9 mg vs 48.5 mg IV morphine equivalents, p=0.002) 2
• Shorter hospital stay (4.0 vs 6.1 days, p=0.050) 2
• Typical procedure time 25-45 minutes via three ports 1
• Discharge typically by postoperative day 2 1

Laparoscopic Approach Limitations

• Longer operative time (194 vs 143 minutes, p=0.053) 2
• Conversion to open occurs in approximately 27% of cases (3 of 11 patients in one series) 2
• Not appropriate for patients with acute midgut volvulus requiring emergent intervention 2

Open Approach Indications

• Acute presentation with midgut volvulus 2
• Hemodynamic instability or peritonitis 6
• Inability to safely complete laparoscopic dissection (cocoon deformity, dense adhesions) 5
• Conversion from laparoscopic when anatomy cannot be safely defined 3, 2

Postoperative Outcomes and Follow-up

• Symptom resolution occurs in 89% of patients (16 of 18 available for follow-up reported complete resolution, 2 felt greatly improved) 2
• Recurrence requiring reoperation is rare (2 recurrences detected, only 1 requiring reoperation in one series) 3
• No volvulus-related reoperations occurred in patients who underwent complete Ladd procedure 2
• Follow-up at 6 months typically shows sustained symptom relief 1

Complications and Risk Mitigation

• Adult patients experience higher complication rates (60%) compared to pediatric patients (29%), though this difference did not reach statistical significance 4
• Common complications include wound infection, delayed gastric emptying, and adhesive ileus 3
• Reoperation rate in adults is significantly higher at 40% (p=0.020) 4
• Critical pitfall: Diagnostic delay is the primary driver of increased morbidity—chronic symptoms lasting 6 months or more occurred in 70% of adults versus 14% of children (p=0.017) 4

Special Considerations

• Malrotation with cocoon deformity (rare variant with peritoneal encasement) can still be managed laparoscopically by experienced surgeons 5
• Incidental discovery at laparotomy for other indications occurred in 58% of cases in one series—proceed with Ladd procedure if anatomy permits 3
• Nutritional optimization before surgery is not typically necessary in malrotation patients, unlike chronic intestinal dysmotility patients 7