Malrotation -Procedures, Side effects, Recovery time, Costs and alternatives

Intestinal malrotation is an abnormality of the intestine when it is not formed in the correct way in the abdomen. It normally occurs early in the pregnancy (around the 10th week) and develops when the intestine fails to coil into the proper position in the abdomen. It is often not witnessed until the baby experiences a twisting of the intestine known as a volvulus. A volvulus is an intestinal disorder that causes an obstruction in the intestine, preventing food from being digested normally. The blood supply to the intestine in the twisted part can also be cut off and this may lead to the death of the intestine’s segment. If not treated as soon as possible this problem can become fatal

Some of the symptoms of mal rotation includes frequent vomiting sometimes in green or yellowish green in colour, swollen &firm abdomen, pale colour skin, poor appetite, little or no urine, blood in stools, fever, lethargy, infrequent bowel movements.

Mal rotation is an emergency situation and the development of volvulus is considered a serious life-threatening condition. Therefore, surgery is required to treat this problem. Firstly, the baby will be given IV (intravenous) fluids to prevent further dehydration and also antibiotics will be given to prevent infection.

If a volvulus is developed it is surgically repaired as soon as possible. First, the intestine is checked for damage. If it is healthy, then it is replaced in the abdomen.

To correct this, a colostomy may be performed to enable the digestive process to continue normally. By colostomy, the two remaining healthy ends of intestine are brought through openings in the abdomen. Stools will pass through the opening called a stomaand then it is collected in collection bag. Depending on the amount of intestine that needed to be removed the colostomy may be temporary or permanent.

Malrotation without volvulus Surgery is usually a scheduled operation. This Malrotation procedure is called “Ladd’s procedure”. It is named after surgeon who invented it. Partial obstruction caused by abnormal bands are released and the blood supply to the intestines is reassured and also the appendix is removed. In malrotation, the appendix is not in the normal position that is why it is removed. Ladd’s procedure can be done the traditional way either open or larger incision or laparoscopic.

Open: In this procedure it is done through a transverse cut in the right upper part of the belly or through a vertical cut in the middle of the belly.

Laparoscopy: Many small cuts or incision are made and through one of the cuts, a video camera is placed. The surgery is also done by using small instruments placed through the other cuts or incisions. The usual number of incisions for laparoscopic surgery vary from one to multiple.

Preoperative preparation: The child should bathe the night before or the morning of surgery. Before the surgery, antibiotics may be given through the vein.

Diet: Once there is evidence that the intestines have recovered from surgery oral feeding will resumed. This varies from patient to patient.

Medicines: Patient will be advised following medicines:

Anti-nausea medicine: To control vomiting.

Pain medicine: Pain killer can include acetaminophen, ibuprofen, or narcotics

Malrotation with volvulus Medicine: Patients suffering from malrotation with midgut volvulus will be given an IV for fluids and antibiotics as medicines to fight infection. If the patient is in mild pain, medications are needed to help relieve discomfort.

Surgery: Mal rotation with volvulus is a surgical emergency. This procedure is usually done through a vertical or horizontal cut in the belly. Firstly, the intestines are untwisted to restore blood flow. The intestines are checked to see how much damage is there. Sometimes, untwisting and restoring blood flow revives intestine. If the intestines are badly damaged and are beyond repair, then they will need to be removed. After the damage to the intestines are checked and taken care of, then a Ladd’s procedure is performed.

Preoperative preparation: Patients need to be given IV fluids and antibiotics through the vein. Blood products transfusion may be needed.

Postoperative care: Patients will be advised to remain on antibiotics after surgery. Until their intestine begins working againpatients will not be fed for a period of time. If there is possibility that some segments of intestine can recover, repeated examinations under anaesthesia may be required prior to final closure.

To evaluate the position of the intestine the doctor advise many tests and perform a thorough physical exam and check whether abdomen is twisted or blocked. Some of the tests may include:

1. Abdominal X-ray: In this X-ray intestinal obstructions are shown.
2. Barium enema X-ray: Barium, a liquid makes the intestine show up better on the X-ray. In this test, barium is inserted into the intestine through the anus and then X-rays are taken.
3. CT scan: CAT (Computerized Axial Tomography). CT scan uses computers and X-rays to produce many pictures from different angles to give doctors an accurate picture of the body. In the case of malrotation, the doctor will go through CT scan to look for a blockage in one of the intestines. A harmless dye may be injected to see the blockage more easily.

Malrotationtreatment depends on the child’s symptoms and the overall health, and the degree of malrotation. Children with complex cardiac problems and malrotationthen surgical intervention is not recommended. For children with such serious conditions, there is high risks for surgery and only little benefit. Children who has symptoms of vomiting and cannot gain good weight for them surgical repair is done on a scheduled basis. Children with volvulus where the blood supply to the intestine is potentially cut off, the treatment is done on an emergency basis. The longer the intestines do not have blood supply, the higher risk it is for the intestines to die.

The posiible side effects of the treatment are : Vomiting of the bile which is greenish-yellow digestive fluid, pain in the abdomen, abdominal distention and swelling, rapid heart rate, rapid breathing, bloody stools.etc. In case any of these side effects persists or there any other health issues arising during or after treatment, it is advised to kindly consult the health specialist immediately.

Although surgery is required to treat intestinalmalrotation, most children experiences normal growth once the problem is treated and corrected. Majority of children who suffer malrotation who experienced a volvulus do not have long-term problems if the volvulus was repaired promptly and there was no intestinal damage. The child's physician should be consulted regarding the specific prognosis for the child.

The child is moved to a hospital room after a surgery. Children who are very ill or may be serious are shifted to the intensive care unit (ICU) or neonatal ICU and then to the room. Children who underwent surgery for malrotation usually stay in hospital for about 7 days, it depends on the rate at which their intestine recovers from the operation.

The child after surgery will need to get fed through an IV line for a few days, because the intestine needs to rest before they start to work again. When the intestines start functioning normally the child will release gas and the doctors will then recommend normal feeding. The doctor should be in constant touch with the child and its family during the entire duration of hospital stay. Once the child is discharged a follow-up visit with the doctor is scheduled from 2-3 weeks after surgery to make sure that the intestine is working properly and the surgical wound is healing properly.

The recovery time for the patient varies from patient to patient based on his or her health condition . The average hospital stay is 11 days. Normally it ranges between 2 to 60 days. Children with multiple congenital abnormalities requiring multidisciplinary care normally experience long hospital stays.

Medication costs may range from Rs: 1000 to Rs: 10,000. The surgery may cost from Rs: 50,000 to Rs: 5 lakhs.

The result depends on what treatment is performed for the problem. It may be temporary or permanent.

Possibly there are no alternatives to surgery for this problem whether mal rotation is with volvulus or without volvulus.