Midterm results for revision total knee arthroplasty for component malrotation.

INTRODUCTION: Accurate positioning of components in total knee arthroplasty (TKA) is essential to a satisfactory outcome. Significant malrotation may lead to chronic pain, stiffness, and dysfunction. This study aims to quantify improvements in functional outcomes following revision surgery for malrotation of either one or both components in TKA versus revision for aseptic loosening. METHODS: This was a retrospective review of TKAs that matched and compared the two-year functional outcomes of the malrotation group to a functionally similar aseptic loosening group. Functional outcomes were compared between groups using Short Form (SF-12), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Knee Society Functional Score (KSFS). Student t-tests and chi-squared or Fisher's tests were used for statistical analysis. RESULTS: Of the patients revised, 24 had malrotation and 57 had aseptic loosening. A total of 16 femoral and 17 tibial components were revised for malrotation. All 16 femoral components were internally malrotated (mean -4.8 ± 4.1 degrees; range, -0.5 to -16.6). Of the tibial components, 15 were internally malrotated, (mean -9.5 ± 6.6 degrees; range, -2.2 to -23.5) and 2 were externally malrotated (mean 4.6 ± 2.1 degrees; range, 3.1 to 6.0). All functional outcome measures significantly improved comparably within both groups preoperatively to 24 months postoperatively. At 24 months, functional outcome measures were comparable between the groups and WOMAC function scores were significantly higher in the malrotation group. CONCLUSION: Revision TKA for malrotation can yield clinically and statistically significant functional improvements, similar in magnitude to those seen following revision TKA for aseptic loosening. LEVEL OF EVIDENCE: Level III.

An incarcerated paraduodenal hernia of a malrotated gut in a 26-year-old man.

Introduction and importance: Paraduodenal hernias (PDHs) are congenital internal hernias. Overall, internal hernias are between 0.2 % and 0.9 %, while 53 % of these statistics are for PDH. There are left and right types of PDHs. CASE PRESENTATION: An otherwise healthy 26-year-old man was presented with a sudden-onset epigastric and right upper quadrant abdominal pain. Abdominopelvic double contrasted CT scan revealed multiple dilated proximal-mid small bowel loops in the portal venous phase consistent with small bowel obstruction, suggesting concomitant bowel malrotation with internal paraduodenal hernia. The patient with the pre-operative diagnosis of small bowel obstruction due to volvulus was scheduled for emergency surgery. He was four weeks complication-free in his regular follow-up. CLINICAL DISCUSSION: In 1857, Treitz first described PDH as a phenomenon when the primitive midgut in embryonic life abnormally rotates and causes mesocolic hernia. The location of the duodenal recess is the origin point for describing the hernia; thus, the jejunum is the most common herniating viscus. However, the stomach, small intestine, and sometimes the colon usually consist of the contents of the hernia. CONCLUSION: In the absence of surgical history, abdominal wall hernia, and intra-abdominal inflammatory disease, in case of repeated abdominal pain or intestinal obstruction, and if no other causes are found, the possibility of a PDH should be kept in mind.

Adult Intestinal Malrotation With Congenital Transverse Meso-Colic Internal Hernia: An Infrequent Cause of Small Bowel Obstruction.

Adult intestinal malrotation along with congenital transverse-mesocolic internal hernia causing small bowel obstruction is extremely rare. Most of these patients don't have any obvious clinical symptoms. Only a few cases have been documented in the English literature. We present the unique case of a 43-year-old male without any prior surgical history who presented with nonspecific abdominal pain and was diagnosed with malrotation of the small intestine by computed tomography (CT) scan and underwent exploratory laparotomy found to have internal herniation through the transverse-mesocolon. The patient underwent an emergency laparotomy; a Ladd's procedure and repair of the hernial orifice were performed. This case highlights the association of adult intestinal malrotation with internal hernias and small bowel obstruction; it also explores the importance of timely diagnosis and adequate management of this condition.

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.

Clinical management of intestinal malrotation in different age groups.

PURPOSE: Intestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation. METHODS: This retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed. RESULTS: The study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus. CONCLUSION: The diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients.

Modified cranial approach to right-sided colon cancer in a patient with intestinal nonrotation: A case report.

Managing colon cancer with intestinal nonrotation, a type of congenital intestinal malrotation, is challenging due to the presence of anatomical abnormalities and severe adhesions. When patients have nonrotation, it is markedly more difficult to determine which vessels correspond to the colic vessels and ileal vessels until all vascular branching patterns become evident. The optimal approach for right-sided colon cancer with intestinal nonrotation has yet to be established. In the present case of ascending colon cancer with intestinal nonrotation, we performed laparoscopic right hemicolectomy with D3 dissection using a modified cranial approach. This approach involves tracing, without resecting, branches from the superior mesenteric vein and superior mesenteric artery in a cranial-to-caudal manner until the ileocolic artery and ileocolic vein, which course toward the cecum, are identified, followed by the dissection of the colic vessels and lymph nodes in a caudal-to-cranial fashion.

Severe Duodenal Bleeding with Heterotaxy Syndrome Controlled by Combined Hemostatic Strategies: A Case Report.

A 73-year-old man with a history of heterotaxy syndrome and intestinal malrotation developed hemorrhagic shock due to bleeding from a duodenal ulcer. Esophagogastroduodenoscopy failed to achieve hemostasis because of restriction of the view by massive hemorrhage. Transcatheter arterial embolization cannot achieve endovascular hemostasis due to the vascular anatomy. Therefore, surgical hemostasis was achieved. Intestinal malrotation due to heterotaxy syndrome is a risk factor for gastrointestinal bleeding. Severe gastrointestinal bleeding in patients with intestinal malrotation is difficult to control with endoscopy alone. Therefore, combined therapies with endoscopy, interventional radiology, surgical procedures, and intensive care are vital for achieving a better prognosis.

Two exploratory laparotomies within six days: A case of midgut volvulus in an adult with congenital malrotation.

INTRODUCTION: Midgut volvulus in adults based on congenital malrotation, which required emergency surgery, may occur under the stimulation of adverse factors and is rare and easy to be misdiagnosed. PRESENTATION OF CASE: A young male was taken to the emergency room of a local hospital after six hours abdominal pain. Computed tomography (CT) shows intestinal volvulus and exploratory laparotomy was performed. Postoperative CT revealed remission of small intestinal torsion and congenital malrotation of the midgut. The patient vomited frequently within 48 h after the surgery, and was transferred to our hospital for conservative treatment. After 4 days of conservative treatment, the vomiting symptoms were relieved at first, but worsened again after a liquid diet. CT showed complete duodenal obstruction and exploratory laparotomy was performed again. Congenital malrotation was found, which resulted in midgut volvulus and duodenal obstruction due to anomalous fixation of the mesentery. The bowel was placed in normal anatomical position, and the mesentery was sutured to the posterior abdominal wall. The patient was followed up for 24 months with no complaints. DISCUSSION: Due to the rare incidence and atypical pain clinical manifestations, it is difficult for the congenital malrotation in adults to be diagnosed. Midgut volvulus in adults with malrotation is even rarer and requires emergency operation, and may be misdiagnosed. CONCLUSION: Midgut volvulus with midgut malrotation is very rare in adults. Exploratory laparotomy must be careful to reduce misdiagnosis and recurrence of volvulus.

Minimally Invasive Osteotomy for Correction of Post-Traumatic Tibia Internal Rotation Deformity: A Case Report.

Introduction: Intramedullary nailing is a commonly performed surgery for tibia diaphysis fractures. However, in selected cases, this procedure can get complicated with rotational malalignment if not checked carefully intra-operatively. Case Report: A 29 year-old male sustained polytrauma and was treated with intramedullary nailing for bilateral femur and right-side tibia fractures. Postoperatively, the patient noticed extreme in-toeing suggesting an internal rotation deformity, which caused great difficulty in walking. The patient was planned for a revision surgery to correct the internal rotation deformity, 6 months after the index surgery. A minimally invasive metaphyseal osteotomy was performed, away from his fracture site by drilling multiple holes. The distal locking bolts of the interlocking nail were removed, and two K wires used to achieve the desired correction angle. After rotating the distal fragment, locking bolts were reinserted in new holes. We kept the patient on our regular follow-up till he achieved sound union at the osteotomy site, after which we allowed him unrestricted activities. Conclusion: The presence of an intramedullary nail can hence help the surgeon in correcting such isolated rotational deformities without getting into the hassle of implant removal to achieve the same.

High risk and low incidence diseases: Pediatric digestive volvulus.

INTRODUCTION: Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION: An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

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.

Description of new sign of integral (∫) for rotational deformity of distal femur.

PURPOSE: Femur shaft fractures commonly occur due to high velocity trauma and most of them are fixed with nailing. Malrotation is common after fixation. A rotational malalignment more than 30° is a deformity which requires correction. Various techniques described for rotational deformities are: the 'cable techniques' for the determination of varus-valgus malalignment; the 'hyperextension test', 'radiographic recurvatum sign', 'tibial plateau sign', and 'meterstick technique' for length analysis; and the 'hip rotation test', 'lesser trochanter shape sign', 'cortical step sign', and 'diameter difference sign' for rotational analysis. We describe integration sign at the medial or lateral aspect of notch of femur in fixed internal or external rotation due to condensation of trabeculae. METHODS: This is a prospective observational study. Informed consent was taken, and this study was approved by institutional review board. C arm imaging study of 50 knees was done at our institution in which rotational profile of distal femur was analyzed In 3 different views -AP , Internal and external rotation views. The rotation views were taken sequentially and each observer was asked to identify the sign at its appearance and at rotation when it was best seen. All the observers were asked to draw the sign on linear line diagram of distal femur. The data was analysed statistically. RESULTS: Sign of integral (∫) for rotational deformity was seen at Mean external rotation of  22±1.71 with a range of 19 degree to 25 degree and  Mean internal rotation of 15.78±1.21 with a range of 14 degree to 18 degree. CONCLUSION: The integration sign can be used as intraoperative C arm sign to understand the rotational deformity of distal fragment of femur. This helps the surgeon to understand the alignment and revise if needed intraoperatively. If combined with position of lesser trochanter, this will give alignment for both proximal as well as distal fragment of femur.

Attempted one anastomosis gastric bypass converted to a sleeve gastrectomy in an adult patient with asymptomatic intestinal malrotation: A case report.

Unexpected encounters during surgery for obesity such as midgut malrotation cause specific technical challenges to the surgeon. We present a rare case of asymptomatic complete intestinal malrotation midway during a one anastomosis gastric bypass procedure. A 62-year-old male with a body mass index of 49 kg/m2 and metabolic syndrome was planned for one anastomosis gastric bypass. A gastric tube was created along the lesser curvature. During the attempt to identify the suitable small bowel loop, an unexpected completely malrotated gut was noted. Due to the intraoperative difficulty in identifying the correct loop to anastomose to the gastric tube an intraoperative decision was taken to convert the procedure to a sleeve gastrectomy. The created gastric tube was re-anastamosed to distal stomach, and the redundant stomach was resected. Postoperative recovery was uneventful, and weight loss was satisfactory. Attempted one anastomosis gastric bypass converted to a sleeve gastrectomy was a successful bailout procedure.

Individual Bilateral Difference of Femur, Tibia, and Leg Rotation: A Clinical Study of 141 Healthy Japanese Individuals Using Computed Tomography.

Background The malrotation of a femur and tibial fracture after surgery has been described in many articles. However, these studies have not considered individual bilateral differences (IBDs). The IBD of femur and tibial rotation has been identified via computed tomography (CT) in recent American studies. The IBD in rotation should be considered during femur and tibial surgery. However, IBDs in femur and tibial rotation remain unknown in the Japanese population. This study aimed to evaluate the rotation of the femur, knee, tibia, and leg, sex differences, and IBD in rotation among Japanese individuals with healthy bones by using CT analysis. Materials and methods In total,141 patients who underwent CT angiography or venography were included (70 men, 71 women; mean age, 44.7 years). The bilateral axial femur, knee, tibia, and leg rotation alignment were independently measured. The distribution, sex, and IBD were analyzed. The IBD in rotation had two statistical factors: absolute bilateral difference (ABD) and relative bilateral difference (RBD). Results The mean ABD of femur rotation was 6.5°, and the distribution of ABD of femur rotation ≤15° was 95%. The mean ABD of tibia rotation was 5.1°, and the distribution of ABD of tibia rotation ≤10° was 89%. The RBD of femur rotation was not significantly different between the right and left sides. The RBD of tibia rotation showed a higher mean external rotation of 3.3° on the right side (<0.001). The Pearson correlation coefficients of the femur, knee, tibia, and leg rotation between the right and left sides were high (r= 0.702-0.81; all, p<0.001). All elements of rotation showed significant differences between men and women, whereas the ABD and RBD of all elements showed no significant difference. Conclusion The distributions of ABD in femur and tibia rotation supported the previous definition of an acceptable rotation difference between the normal and fractured femur and tibia of ≤15°and ≤10°, respectively. The possibility of higher external rotation on the right side needs to be taken into account during tibial surgery.

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.

Comparison of anatomic axes with a navigated functional rotation axis determined by ligament tension for rotational femoral component alignment in cadaver knee arthroplasty.

INTRODUCION: The malimplantation of the total knee arthroplasty (TKA) components is one of the main reasons for revision surgery. For determining the correct intraoperative femoral rotation several anatomic rotational axes were described in order to achieve a parallel, balanced flexion gap. In this cadaveric study prevalent used rotational femoral axes and a navigated functional rotational axis were compared to the flexion-extension axis defined as the gold standard in rotation for femoral TKA component rotation. MATERIALS AND METHODS: Thirteen body donors with knee osteoarthritis (mean age: 78.85 ± 6.09; eight females and five males) were examined. Rotational computer tomography was performed on their lower extremities pre- and postoperatively. Knee joint arthroplasties were implanted and CT diagnostics were used to compare the preoperatively determined flexion-extension axis (FEA). The FEA is the axis determined by our surgical technique and serves as an internal reference. It was compared to other axes such as (i) the anatomical transepicondylar axis (aTEA), (ii) the surgical transepicondylar axis (sTEA), (iii) the posterior condylar axis (PCA) and (iv) the functional rotation axis (fRA). RESULTS: Examination of 26 knee joint arthroplasties revealed a significant angular deviation (p*** < 0.0001) for all axes when the individual axes and FEA were compared. aTEA show mean angular deviation of 5.2° (± 4.5), sTEA was 2.7° (± 2.2), PCA 2.9° (± 2.3) and the deviation of fRA was 4.3° (± 2.7). A tendency towards external rotation was observed for the relative and maximum axis deviations of the aTEA to the FEA, for the sTEA and the fRA. However, the rotation of the posterior condylar axis was towards inwards. CONCLUSIONS: All axes showed a significant angular deviation from the FEA. We conclude that the presented technique achieves comparable results in terms of FEA reconstruction when compared with the use of the known surrogate axes, with certain deviations in terms of outliers in the internal or external rotation.

Quadruple (1440 degrees) intestinal volvulus.

Key Clinical Message: A whirl sign on contrast-enhanced abdominal CT scan is indicative of intestine twisted around the mesenteric vessels, and is observed in cases of strangulated obstruction, signaling compromised intestinal circulation. In cases of intestinal volvulus, surgery is necessary to untwist the affected bowel, and resection is necessary if necrosis is present. Abstract: A 31-year-old Japanese man presented with acute lower abdominal pain and vomiting. Contrast-enhanced abdominal computed tomography (CT) revealed a 1440-degree clockwise torsion of superior mesenteric artery and a whirl sign. Intestinal volvulus in adulthood with a background of malrotation is extremely rare. Contrast-enhanced CT is effective for diagnosis.

No safe time window in malrotation and volvulus: A consecutive cohort study.

BACKGROUND: Malrotation and volvulus classically present with bilious vomiting. It is more common earlier in life, but there are other causes of bile-stained vomiting. This leads some clinicians to 'watch and wait'. In the presence of a volvulus, this is potentially a fatal decision. It is not clear from the literature if there is a safe time window in which children can be observed in the hope of avoiding transfers or radiological investigations. AIM: To determine whether time to identification and management of midgut volvulus correlated with morbidity and mortality; and whether there were patterns to transition of care. METHODS: Multicentre, retrospective review of all children with malrotation ± volvulus at two tertiary children's hospitals in Brisbane from 2000 to 2012. Data collected included age at presentation, timing between symptom onset and presentation, radiological findings, and definitive surgical management. Outcomes included patient length of stay (LOS), total parenteral nutrition (TPN) duration, re-operations and death. RESULTS: There were 96 cases of malrotation identified, with 23 excluded (elective operation, insufficient data). Neonates made up 66% of included cases. Only 14% of cases were over 12 months old. Bilious vomiting or bile-stained aspirates were the presenting symptoms in 71% (52). Overall mortality was 5.56%. Time from symptom onset to presentation or management was not significantly associated with morbidity or mortality. More than half (53%, 39/73) of patients received total parenteral nutrition; 20/39 for more than 10 days. Neonates and infants had a significantly higher rate of TPN compared with older children (P < 0.001). Those requiring TPN post-operatively had a significantly higher mortality compared with those who did not (P = 0.02). Time from symptom onset to presentation or definitive management was not significantly associated with LOS, TPN duration, or need for re-operation. CONCLUSION: Malrotation remains a time-critical diagnosis to secure and treat. Even a short duration of symptoms can be associated with high morbidity or mortality. There is no place for 'watch and wait' for such patients, and malrotation/volvulus should be emergently actively excluded with contrast studies.

Right paraduodenal hernia presenting with strangulated obstruction with intestinal malrotation: a case report.

A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up.