Recurrent midgut volvulus in an adult patient - The case for pexy? A case report and review of the literature

Abstract

Introduction: Intestinal malrotation is a rare condition, with an incidence estimated between 0,2 to 1%. Most cases are diagnosed and treated during childhood. Adult presentations are rare and most adults present with chronic nonspecific complaints. Midgut volvulus is the most feared complication of intestinal malrotation, far more common among the pediatric than the adult population. Presentation in adulthood with a midgut volvulus accounts for a minority of these patients (15%). The Ladd procedure is the standard surgical management of midgut volvulus and intestinal malrotation. Most evidence on the outcomes of the Ladd procedure originates from studies on pediatric population and the recurrence among children who have had a Ladd procedure is low (2-7%).

Presentation of case: We report an exceedingly rare case of a patient who presented in adulthood with a midgut volvulus and less than two years after undergoing Ladd procedure presented with a recurrence of the midgut volvulus. The recurrent midgut volvulus was successfully treated by a fixation procedure (cecopexy and duodenopexy).

Conclusion: Reports of midgut volvulus in adult patients are scarce and reports of recurrence even scarcer hence the rate of recurrence among adult patients has yet to be determined. The recurrence rate in some of the available adult series is much higher than the rate reported among children. Should the rate of recurrence among adult patients prove higher, it poses the question of whether the Ladd procedure should be modified to include bowel fixation when performed in adults.

Keywords: Case report; Intestinal malrotation; Ladd procedure; Midgut volvulus; Recurrent.

Fig. 1

Abdominal x-ray unremarkable except for a decrease in bowel air content.

Fig. 2

Abdominal ultrasound with whirlpool sign (white arrow) - hallmark of superior mesenteric vessels torsion.

Fig. 3

Abdominal CT scan showing aberrant bowel placement (yellow arrow) and mesenteric vessel torsion (red arrow).

Fig. 4

Intra-operative findings at laparotomy: abnormal positioning of the cecum (A); view of the midgut volvulus (B) and Ladd bands (C).