Radiological versus clinical evidence of malrotation: Role of laparoscopy/laparotomy in Indian scenario.

Sir,

Malrotation can have varying levels of symptoms and signs and poses a significant diagnostic challenge. Bilious vomiting is always a concern because of its association with surgical aetiology. Bilious vomiting, in conjunction with abdominal pain, is considered to be a surgical problem, unless proved otherwise. In the neonatal period, this vomiting is due to high small bowel obstruction resulting from atresia, stenosis and malrotation, etc. In Indian children, besides tuberculosis, jejunal stricture due to nonspecific jejunoileitis was found to be an important cause of chronic high small bowel obstruction and bilious vomiting.[1]

Usually, the diagnosis of malrotation is made on imaging that is upper gastrointestinal (UGI) contrast study. In our institute, ultrasound is used as a diagnostic adjunct to aid decision making. Imaging studies may be inaccurate in differentiating malrotation from nonrotation or normal rotation. Laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children without a narrow-based mesentery can undergo laparoscopy alone, and those with malrotation should undergo either laparoscopic or open Ladd procedure.[2] In developing countries like India with limited resources, lack of adequate knowledge and poverty, delayed presentation is quite common. Atypical presentation can delay the diagnosis resulting in increased morbidity. As early features might not be typical of malrotation, a high index of suspicion is necessary to avoid morbidity. Hence in every case of radiological evidence of malrotation in children irrespective of signs and symptoms, we do laparotomy/laparoscopy depending on the patient condition.

Findings of UGI study and symptoms only decide the timing of surgery that is emergency or routine, but cannot postpone the surgery. UGI contrast study can occasionally be misleading. There is a significant rate of negative laparotomy following diagnosis of malrotation on UGI contrast study.[3] Therefore, all parents of patients undergoing laparotomy for malrotation should be informed of the risk of negative laparotomy as part of the consents process. Laparoscopy can be a good option in Indian children, where besides malrotation, tuberculosis and jejunal stricture due to nonspecific jejunoileitis was found to be an important cause of chronic high small bowel obstruction and bilious vomiting.