K. Bergus2, D. Duvall4, J. Morris3,4, B. Albers3, S. R. Carter1,5 1University Of Louisville, Surgery, Louisville, KY, USA 2Nationwide Children’s Hospital, Pediatric Surgery, Columbus, OH, USA 3Norton Children’s Hospital, Pediatric Radiology, Louisville, KY, USA 4University Of Louisville, Radiology, Louisville, KY, USA 5Norton Children’s Hospital, Pediatric Surgery, Louisville, KY, USA
Introduction: Symptomatic malrotation requires prompt evaluation and treatment with a Ladd procedure. Asymptomatic patients with incidentally found intestinal rotational abnormalities (IRA) present a clinical dilemma as both mandatory and selective operative management is described. Algorithms based on fluoroscopic identification of the duodenojejunal (DJJ) and ileocecal junction (ICJ) have been proposed for operative decision-making but have neither been validated nor gained wide acceptance. This study evaluated whether the ratio of fluoroscopic measurement of the mesenteric base width (MBW) compared to abdominal wall diameter (AWD) correlates with operative findings in infants with IRA.
Methods: We retrospectively reviewed patients <1 year old with fluoroscopic upper gastrointestinal study and either small bowel follow-through, contrast enema, or x-ray between 2013-2023. Patients with symptomatic and asymptomatic IRA and normally rotated patients who underwent imaging for digestive concerns were included. Patients with gastroschisis, omphalocele, intestinal atresias, congenital diaphragmatic hernias, and Situs Inversus were excluded. Three radiologists independently measured MBW as a line from the DJJ to the ICJ and the maximal transverse AWD from inferior ribs (Figure 1). A ratio was calculated and compared between normally rotated patients and IRA using Wilcoxon signed rank and Kruskal-Wallis tests, with p<0.05 considered significant.
Results: Fifty-eight infants, 22 normally rotated and 36 with IRA, were included. Of those with radiographic IRA, 32 (89%) had operative confirmed IRA. Preoperative concern for malrotation based on the radiologist’s interpretation differed between IRA and normally rotated patients (p<0.0001). Mean MBW:AWD was significantly lower in IRA than normal rotation based on prior imaging (0.39 vs 0.65, p<0.0001). This trend persisted when comparing MBW:AWD between classic malrotation with other rotational variants (i.e. non-rotation, reverse rotation) (0.35 vs 0.48, p=0.0099).
Conclusion: Measurement of MBW:AWD using fluoroscopically identified landmarks appears to perform comparably to the radiologist’s preoperative concern for malrotation. Additional definition of a spectrum of MBW:AWD measurements could help differentiate anatomic variants of intestinal rotation in the preoperative setting. Further validation is necessary prior to determining whether this ratio should play a role in operative decision-making for asymptomatic patients with IRA.
