Late presentation of midgut malrotation with obstruction in a 5-year-old female: A case report.

Midgut malrotations are rarely diagnosed beyond infancy. Delays in recognition and diagnosis can result in death. Here, we report the case of a 5-year-old girl who presented with a 1-year history of intermittent abdominal pain and vomiting. An abdominal computed tomography scan with contrast confirmed the diagnosis of midgut malrotation with obstruction; therefore, the Ladd procedure was performed, and the child was discharged uneventfully. Clinicians must maintain a high level of suspicion because this diagnosis is unusual in this age group.

Laparoscopic Versus Open Ladd Procedure for Midgut Malrotation.

INTRODUCTION: Intestinal malrotation is an uncommon developmental anomaly that can lead to duodenal obstruction and midgut volvulus. The standard correctional operation, Ladd's operation, is traditionally performed using an open approach, but providers are increasingly performing the procedure laparoscopically. However, there remains concern that the reduced adhesive burden associated with laparoscopy could predispose to recurrent volvulus. METHODS: We queried our institutional database from 2012 to 2022 for patients <18 years who underwent Ladd's operation for malrotation. We analyzed baseline characteristics and outcomes including post-operative volvulus, adhesive small bowel obstruction (SBO), duodenal obstruction, and overall abdominal re-operation. RESULTS: We identified 226 patients, of whom 90 (40%) underwent a laparoscopic operation. Those undergoing open surgery were younger and had a higher rate of volvulus compared to laparoscopic patients. There were no differences in surgical history or underlying comorbidities. Laparoscopic patients were less likely to develop a post-operative adhesive SBO [1/90 (1%) vs 14/136 (10.0%); OR 9.4 (1.7-176.4), p = 0.036] with no increased rate of volvulus [1/90 (1%) vs 1/136 (0.7%), p = 0.778]. However, there were four laparoscopic patients that required re-operation for a duodenal stricture or kink, which led the overall rate of abdominal re-operation to not be different [7/90 (8%) vs 16/136 (12%); OR 1.6 (0.6-4.8), p = 0.371]. Median follow up was 2.3 years [IQR 1.0-5.0]. CONCLUSION: Laparoscopic correction of midgut malrotation demonstrates no increased risk of post-operative volvulus and may reduce the rate of adhesive SBO. These benefits must be weighed against the potential increased risk of duodenal stricture or obstruction secondary to an incomplete Ladd's procedure. LEVEL OF EVIDENCE: III.

Comparative Efficacy of Fractional CO2 Laser Combined with Topical Steroid Cream versus Solution for Post-Thyroidectomy Scar Treatment: A Prospective Study.

BACKGROUNDS: Post-thyroidectomy scarring is a common illness impacting patient quality of life. Fractional carbon dioxide (CO2) lasers and topical steroids delivered via laser-assisted drug delivery (LADD) have shown potential for scar treatment. However, ideal steroid formulations (cream vs. solution) when combined with laser therapy remain unclear. METHODS: This study included 12 patients receiving fractional CO2 laser on post-thyroidectomy scars. After laser treatment, one scar half received topically applied steroid cream, while the other half received steroid solution. The Patient and Observer Scar Assessment Scale (POSAS) was used to measure the scar conditions at the time prior to the first treatment and one year later by the patients themselves and by the surgeon who did the laser treatment. Scar appearance was photographically assessed at baseline and 6 months post-treatment by four blinded evaluators using scales. RESULTS: This study discovered a modest improvement in the appearance of post-thyroidectomy scars when combining fractional CO2 laser treatment with either topical steroid cream or solution. Patients and treating physicians examined the POSAS scores one year after treatment found significant improvements in all aspects of the scar conditions, with high efficacy and satisfaction levels reported by patients. CONCLUSIONS: Fractional CO2 laser combined with topical steroid delivery, either cream or solution form, significantly enhanced post-thyroidectomy scar appearance with modest effect and high patient satisfaction. This approach may represent a promising scar management strategy along with current scar treatment for the post-thyroidectomy scar.

A Rare Case of Delayed Presentation of Acute Midgut Volvulus in an Adolescent.

Intestinal malrotation is primarily diagnosed in the neonatal period, when symptoms typically first appear. In contrast, occurrences in adults are quite uncommon. Adult cases are less frequently reported, often because the condition remains asymptomatic or presents with nonspecific symptoms that can delay diagnosis. Intestinal malrotation in adults can show a range of symptoms, from acute bowel obstruction to vague and chronic symptoms, often leading to a delay in the diagnosis compared to children. Patients with this condition present a distinctive challenge for surgeons regarding diagnosis and treatment, especially in acute situations. This study presents a rare case of a 16-year-old boy who came with chief complaints of acute abdominal pain and multiple episodes of bilious vomiting. The patient underwent an emergency laparoscopy converted to an open Ladd's procedure. During surgery, the duodenum, small intestine, cecum, and appendix were discovered to be abnormally positioned, and the transverse colon and mesentery were twisted along with the superior mesenteric artery and superior mesenteric vein, with the presence of classical Ladd's bands confirming preoperative CT findings of midgut volvulus. The patient tolerated the procedure well, with no intraoperative complications. Acute midgut volvulus is rare in adults and older children. Still, the differential diagnosis should be kept in mind in patients with pain in the abdomen and multiple episodes of bilious vomiting in cases with an uncertain diagnosis to plan proper management and avoid intraoperative surprises. Early detection, accurate imaging methods, and prompt intervention can mitigate complications that could increase morbidity and mortality.

An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation.

Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure.

BACKGROUND: The Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure. METHODS: A retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL). RESULTS: A total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10-50), operative time was 2.3 h (IQR, 1.8-2.8), and hospital length of stay was 2 days (IQR, 2-3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25-13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition. CONCLUSION: The laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

Gut Malrotation in a Human Cadaver: Exploration Into the Prevention and Screening of Undiagnosed Malrotation in Adults.

Malrotation is a congenital anomaly that results from the abnormal rotation of the gut during fetal development. Malrotation may be missed in early life and can present later with non-specific, chronic abdominal symptoms and decreased quality of life and in some cases can lead to serious bowel complications. Most adult cases are discovered incidentally on imaging or during surgery. An 82-year-old male cadaver was identified as having probable malrotation of the intestines. The performance of a previous surgical procedure could not be confirmed due to a lack of medical and surgical history. The cadaver dissection raised the question regarding the screening modalities used to reliably identify malrotations in infants and adults. Implementing a standardized reliable screening tool in infants or adults complaining of chronic abdominal pain could largely reduce the incidence of undiagnosed malrotation. Along with the development of a screening tool, increasing understanding of the clinical presentation of malrotation in adults could help identify undiagnosed cases earlier, which can reduce morbidity and mortality in these patients.

Duodenal stenosis in adult malrotation: When Ladd procedure is not enough: A case report.

INTRODUCTION: Congenital causes of duodenal obstruction can be grouped into intrinsic and extrinsic causes. The degree of obstruction caused by such etiologies determines the severity and timing of symptom presentation. Early neonatal diagnosis is common in patients with etiologies that present with high degrees of obstruction such as atresia whereas etiologies that cause lesser degrees of obstruction such as malrotation and duodenal stenosis can go undiagnosed into adulthood. PRESENTATION OF CASE: We report a case of a 24-year-old female who presented with acute on chronic abdominal pain with bilious vomiting. She was diagnosed with intermittent small bowel volvulus which resolved spontaneously but was found to have adult intestinal malrotation diagnosed intraoperatively. She had a Ladd procedure done but had persistent obstructive small bowel symptoms after the Ladd procedure. She was found to have duodenal stenosis from fibrosis of the duodenum on relaparotomy which was treated surgically with Heineke-Mikulicz strictureplasty leading to total resolution of symptoms. DISCUSSION: Congenital extrinsic and intrinsic causes of partial duodenal obstruction such as Ladd bands in malrotation and duodenal stenosis respectively, can co-exist and persist into adulthood due to their lesser symptomatology and degree of obstruction. Surgical treatment must identify and correct both conditions when they co-exist to ensure complete resolution of symptoms. CONCLUSION: This case report highlights the association of duodenal stenosis with adult malrotation which may account for persistent symptoms after the Ladd procedure and suggests the use of Heineke-Mikulicz strictureplasty as a complementary procedure for complete symptom resolution.

Midgut volvulus in an adult without significant intestinal obstruction: A case report.

Mid gut volvulus is a rare clinical presentation in adults though it frequently occurs in infants and children. We report a case of 30 years male (post renal transplant patient) who presented with symptoms of abdominal pain, nausea and vomiting for 3 days. After demonstration of twisting of bowel loops around mesenteric vessels on Ultrasonography (USG). Contrast enhanced computed tomography (CECT) abdomen was done which showed small bowel malrotation, inverted relation of Superior mesenteric artery-Superior mesenteric vein and whirl pool sign of midgut volvulus. However, no significant bowel obstruction was noted. Patient underwent explorative laparotomy with ladd's procedure. Post-operatively, it was uneventful. Patient became symptoms free and was discharged after 5 days of surgery. Intestinal malrotation is a congenital abnormality that arises from disrupting the 270◦ counterclockwise midgut rotation during the embryonic period. In our case malrotation was predisposing factor for volvulus. CECT abdomen is the imaging procedure of choice in adults. Ladd's procedure is the treatment of choice in symptomatic patients though it remains controversial in asymptomatic patients. Though midgut volvulus is rare in adults, it should be kept as differential in adults with symptoms of intestinal obstruction and workup should be done accordingly.

Identification and treatment of intestinal malrotation with midgut volvulus in childhood: a multicenter retrospective study.

Background: Intestinal malrotation is a rare condition, and its delayed diagnosis can lead to fatal consequences. This study aimed to investigate the identification and treatment of malrotation in children. Methods: Clinical data, imaging, operative findings, and early postoperative outcomes of 75 children with malrotation were retrospectively analyzed. Results: The mean age was 6.18 ± 4.93 days and 51.26 ± 70.13 months in the neonatal group (56 patients) and non-neonatal group (19 patients), respectively. Sixty-seven patients were under the age of 1 year at the time of diagnosis. The occurrence of bilious vomiting and jaundice was significantly higher in the neonatal group (89.29%) than that in the non-neonatal group (37.5%), p < 0.05 and p < 0.01, respectively. The incidence of abnormal ultrasound (US) findings was 97.30% and 100%, respectively, and the sensitivities of the upper gastrointestinal series were 84.21% and 87.5%, respectively. Sixty-six (88%) patients had midgut volvulus, including in utero volvulus (two patients) and irreversible intestinal ischemia (four patients). Most neonates (89.29%) underwent open Ladd's procedure with a shorter operative time (p < 0.01). Reoperation was performed for postoperative complications (four patients) or missed comorbidities (two patients). Conclusions: Non-bilious vomiting was the initial symptom in >10% of neonates and nearly 40% of non-neonates. This highlights the importance for emergency physicians and surgeons to be cautious about ruling out malrotation in patients with non-bilious vomiting. Utilizing US can obviate the need for contrast examinations owing to its higher diagnostic accuracy and rapid diagnosis and can be recommended as a first-line imaging technique. Additionally, open surgery is still an option for neonatal patients.

A rare case of extremely low birth weight infant with Beckwith-Wiedemann syndrome.

INTRODUCTION: Beckwith-Wiedemann syndrome (BWS) manifests distinctive features, such as macroglossia, overgrowth, and abdominal wall defects. In this report, we describe a case of BWS in an extremely low birth weight infant diagnosed at three months after birth because of the intensive care for low birth weight. PRESENTATION OF CASE: A female infant was delivered at 24 weeks and 6 days of gestation with a weight of 845 g. After birth, significant small intestinal intra-umbilical prolapse was observed, and abdominal wall closure using a sutureless method was performed on day zero. Careful neonatal management was performed; however, an episode of bloody stools led to a diagnosis of intestinal volvulus due to intestinal malrotation. At 119 days of age, the Ladd procedure was performed. Notably, during anaesthesia induction, features suggestive of BWS were observed, leading to its diagnosis. DISCUSSION: Early diagnosis of BWS is vital because of its association with tumors. However, because she was an extremely low birth weight infant who required oral intubation and supine management for respiratory control, nevus flammeus and macroglossia were not observed. Therefore, BWS was not diagnosed for approximately three months after birth. It is important to recognize that omphalocele in extremely low birth weight infants is a risk factor for delayed diagnosis of BWS. CONCLUSION: Timely diagnosis of BWS is critical because of its association with tumors and varied clinical presentations. Early screening, especially for tumors, and awareness among surgical practitioners can aid in timely interventions and improved patient outcomes.

Small bowel obstruction in adults, Ladd's band is an exceptional cause: a case report.

Malrotation of the gut is a congenital anomaly of foetal intestinal rotation and it's principally discovered in early childhood as acute intestinal obstruction. This condition is veritably rare and constantly silent in adults. Intestinal malrotation in adults is frequently asymptomatic and is diagnosed as a casual finding during a radiological examination performed for other reasons. Infrequently, it can be diagnosed in adults, associated with an acute abdomen. Adult patients rarely present with acute midgut volvulus or internal hernias caused by Ladd's bands. We present a case of an admitted 18-year-old female with a small bowel obstruction due to an intestinal volvulus complicating intestinal malrotation in the presence of Ladd's band. Laparotomic Ladd's procedure was performed successfully with division of Ladd's band, adhesiolysis, appendicectomy, and reorientation of the small bowel on the right and the cecum and colon on the left of the abdominal cavity; the postoperative evolution was favorable. Although it is a rare pathology, it should be kept in mind in cases of patients presenting small bowel obstruction.

Total small bowel volvulus on incomplete common mesentery, an exceptional complication in geriatric patients: A rare case report.

INTRODUCTION AND IMPORTANCE: The incomplete common mesentery, resulting from a rotational anomaly, is a rare but potentially life-threatening condition. This congenital anomaly is characterized by persistent embryonic bowel arrangement and an extremely short mesentery root. Complications typically manifest during neonatal or pediatric stages, with limited occurrences in adulthood. Herein, a compelling case of an 83-year-old male with small bowel volvulus and incomplete common mesentery, underscoring the critical importance of recognizing and addressing rare but potentially life-threatening complications in the geriatric population. CASE PRESENTATION: An 83-year-old male, post-prostatectomy, presented with acute abdominal distress, indicating small bowel volvulus associated with incomplete common mesentery. Dehydration signs were evident on admission, and imaging confirmed the diagnosis. Urgent surgical intervention, including the Ladd procedure, successfully resolved the condition with a six-day recovery. CLINICAL DISCUSSION: Fetal digestive tract rotation anomalies lead to incomplete common mesentery, posing risks of volvulus. Complications, whether acute or chronic, require timely recognition. Diagnostic modalities, including the "whirlpool" sign on imaging, play a vital role. The Ladd procedure remains the standard treatment, addressing mesenteric anomalies and preventing recurrence. CONCLUSION: This case highlights the critical nature of small bowel volvulus with incomplete common mesentery, emphasizing the importance of recognizing and managing this rare condition promptly. Awareness, diagnostic accuracy, and timely surgical intervention are crucial for favorable outcomes, particularly in the geriatric population.

An interesting twist: 90 year-old female with acute small bowel obstruction due to midgut volvulus.

We report an exceptionally rare presentation of midgut volvulus secondary to malrotation in a nonagenarian female. According to our extensive literature review, this 90-year-old female is the oldest reported case of midgut volvulus. This patient presented with acute recurrent emesis. Imaging showed midgut volvulus with associated small bowel obstruction. The patient underwent an exploratory laparotomy that revealed midgut volvulus because of congenital malrotation and Ladd's bands, necessitating a modified Ladd's procedure. The patient had an uneventful postoperative course. Congenital malrotation with Ladd's bands was likely asymptomatic throughout this patient's life. Our case adds to the scarce instances where midgut volvulus with malrotation is identified in elderly patients, underscoring the importance of considering this diagnosis irrespective of age. We recommend including midgut volvulus because of malrotation in a differential list of atypical small bowel obstruction in elderly patients.

Massive Chylous Ascites in a 9-Year-Old Girl with Malrotation-A Case Report.

Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast-enhanced magnetic resonance lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body magnetic resonance imaging revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd's procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 L of fluid. She was discharged the day after surgery and has been in good health for 1 year. We present a video illustrating the Ladd's procedure steps in this patient.

[Treatment of therapy-resistant verruca plantaris with laser-assisted photodynamic therapy (PDT) with methyl aminolevulinate (MAL)]. / Therapie von behandlungsresistenten Mosaikwarzen mittels laserassistierter photodynamischer Therapie (PDT) mit Methylaminolävulinat (MAL).

Mosaic warts are a type of verruca vulgaris that occur almost exclusively on the soles of the feet. They are particularly known for their treatment resistance and high recurrence rate. Laser-assisted drug delivery (LADD) photodynamic therapy (PDT) with methyl aminolevulinate (MAL) offers a low pain treatment option with hardly any side effects in therapy-resistant cases of verruca plantaris. Pretreatment with an ablative fractional laser is especially important to obtain penetration of MAL through the human papillomavirus (HPV)-infected skin layer.

CATSHL syndrome, a new family and phenotypic expansion.

We report the case of a 12-year-old girl and her father who both had marked postnatal tall stature, camptodactyly and clinodactyly, scoliosis and juvenile-onset hearing loss. The CATSHL (CAmptodactyly - Tall stature - Scoliosis - Hearing Loss syndrome) syndrome was suspected, and molecular analysis revealed a hitherto unreported, monoallelic variant c.1861C>T (p.Arg621Cys) in FGFR3. This variant affects the same residue, but is different than, the variant p.Arg621His reported in the two families with dominant CATSHL described so far. Interestingly, peg-shaped incisors were observed in the proband, a feature never reported in CATSHL but typical of another FGFR3-related condition, LADD (Lacrimo - Auricolo - Dento - Digital) syndrome. The FGFR3 p.Arg621Cys variant seems to be a newly identified cause of CATSHL syndrome with some phenotypic overlap with the LADD syndrome.

Laparoscopic Ladd's procedure for intestinal malrotation in small infants with midterm follow-up.

BACKGROUND: The objective of this study was to evaluate the safety and efficacy of laparoscopic Ladd's procedure (LL) for intestinal malrotation (IM) in small infants. METHODS: All patients aged < 6 months with IM who underwent Ladd's procedures between January 2012 and December 2019 were enrolled. The perioperative demographics and midterm follow-up results were retrospectively reviewed and compared between patients who underwent LL and open Ladd's operation (OL). RESULTS: Fifty-five patients were enrolled for analysis. The baseline characteristics were well matched in the two groups. The rate of volvulus was similar in the two groups (76.2% vs. 73.5%, P = 0.81). Two cases in the LL group were converted to OL due to intraoperative bleeding and intestinal swelling. The operative time (ORT) was not significantly different between the two groups (73.8 ± 18.7 vs. 66.8 ± 11.6 min, P = 0.76). Compared to the OL group, the LL group had a shorter time full feed (TFF) (3.1 ± 1.2 vs. 7.3 ± 1.9 days, P = 0.03) and a shorter postoperative hospital stay (PHS) than the OL group (5.5 ± 1.6 vs. 11.3 ± 2.7 days, P = 0.02). The rate of postoperative complications was similar in the two groups (9.5% vs. 11.8%, P = 0.47). The LL group had a lower rate of adhesive obstruction than the OL group, but the difference was not significant (0.0% vs. 11.8%, P = 0.09). One patient suffered recurrence in the LL group, while 0 patients suffered recurrence in the OL group (4.8% vs. 0.0%, P = 0.07). The rate of reoperation in the two groups was similar (4.8% vs. 8.8%). CONCLUSIONS: The LL procedure for IM in small infants was a safe and reliable method that had a satisfactory cosmetic appearance and shorter TFF and PHS than OL.

Superior Mesenteric Vein Dilatation With Ladd's Band Causing Partial Intestinal Obstruction in a Five-Year-Old Male Child: A Case Report.

Midgut malrotation has a noticeable frequency among congenital anomalies and presents mostly as vomiting. We report a case of a five-year-old boy with recurrent attacks of bilious vomiting and mild epigastric colicky abdominal pain for a year. Midgut malrotation with Ladd's band and superior mesenteric vein (SMV) dilatation causing partial intestinal obstruction were diagnosed based on the clinical presentation, upper gastrointestinal (GI) barium follow-through study, computed tomography (CT) scan with and without IV contrast, and intraoperative findings. In the upper GI barium study, the duodenum was passing anteriorly, and the second and proximal third portions were persistently dilated with recurring to-and-fro type peristalsis, resulting in delayed passage through the third portion. In the abdomen and pelvis CT scan with and without IV contrast, the SMV was dilated, forming a venous collar around the third portion of the duodenum and causing partial obstruction. Exploratory laparotomy revealed a hugely dilated SMV trapped in the Ladd's band. Ladd's procedure was done besides releasing the SMV and widening the root of the mesentery. The postoperative follow-up was smooth, without any relapse of the previous symptoms. Midgut malrotation in the older age group is rare in itself because there are relatively few cases documented in this age range. We determined to present this case to raise awareness of knowledge concerning the diagnosis and timely management of this condition in order to prevent comorbidity. In addition, we realise that SMV dilatation is an uncommon correlation of the known condition, midgut malrotation, and hope to contribute to the literature.

A Three-Year Analysis of Toxic Benzene Levels and Associated Impact in Ploiesti City, Romania.

This study examines the levels of benzene and the potential health impact during three years of continuous monitoring (2019-2021), including the COVID-lockdown period from 2020 in a city that is an important Romanian center for petroleum refining and associated product manufacturing. The dataset contains benzene, toluene, NOx, PM10 concentrations, and meteorological factors monitored by six automatic stations from the national network of which four are in the city and two outside. Special attention was given to the benzene dynamics to establish patterns related to the health impact and leukemia. An assessment of the exposure was performed using EPA's ExpoFIRST v. 2.0 for computing the inhalation Average Daily Dose (ADD) and Lifetime Average Daily Dose (LADD). The health impact was estimated based on several indicators such as lifetime cancer risk (LCR), Hazard Quotient (HQ), Disability-Adjusted Life Years (DALY), and Environmental burden of disease (EBD). Overall, the annual average of all stations was almost similar between years i.e., 3.46 in 2019, 3.41 in 2020, and 3.63 µg/m3 in 2021, respectively. The average of all stations during the lockdown period was 2.67 µg/m3, which was lower than the multiannual average of the 2019-2021 period, i.e., 3.5 µg/m3. Significant correlations were present between benzene and other pollutants such as NOx (r = 0.57), PM10 fraction (r = 0.70), and toluene (r = 0.69), and benzene and temperature (r = -0.46), humidity (r = 0.28), and wind speed (r = -0.34). Regarding the ADD, in all scenarios, the most affected age categories are small children, despite a lower outdoor exposure time. From birth to <70 years, the ADD varied depending on the exposure scenario resulting in 3.27 × 10-4, 5.6 × 10-4, and 4.04 × 104 mg/kg-day, and 3.95 × 10-4, 10.6 × 10-4, and 6.76 × 10-4 mg/kg-day for the LADD, respectively. The Integrated Lifetime Cancer Risk (ILTCR) values were 14.1 × 10-5 in winter, 9.04 × 10-5 in spring, 8.74 × 10-5 in summer, and 10.6 × 10-4 in autumn. The ILTCR annual averages were 1.08 × 10-4 (2019), 1.07 × 10-4 (2020), 1.04 × 10-4 (2021), and 1.06 × 10-4 for the entire period. The resulting ILTCR values point out very risky conditions, with the annual averages reaching the definite cancer risk category. The corresponding burden based on the DALY's loss due to leukemia in Ploiesti was estimated at 0.291 (2 µg/m3 benzene), 0.509 (3.5 µg/m3 benzene), 0.582 (4 µg/m3 benzene), and 0.873 DALYs per 100,000 inhabitants (6 µg/m3 benzene), respectively. The current study provides useful insights for a better understanding of the exposure levels to benzene and associated health impact in Ploiesti despite the limitations determined by the data hiatus and incomplete or missing information regarding the health impact.