Infant malrotation with midgut volvulus: A retrospective review of clinical presentation and delays in care at a Canadian tertiary paediatric centre.

Abstract

Objectives: Evaluate clinical presentation, delays and outcome in management of children with malrotation with midgut volvulus to identify avenues for care improvement.

Methods: A retrospective cross-sectional observational study in a single tertiary care paediatric centre on patients with a final diagnosis of midgut volvulus presenting to the emergency department (ED)/neonatal intensive care unit (NICU) from January 2015 through August 2022. Data recorded included demographics, clinical presentation, imaging, surgical findings, and survival/complications. We recorded time from arrival to hospital to: (1) medical evaluation, (2) radiologic investigations, (3) surgery consultation, and (4) surgery. Outcomes included survival and major morbidity.

Results: Thirty children had a diagnosis of midgut volvulus (ED: 22, NICU: 8). Twenty-eight (93%) survived, including two with short bowel syndrome. Median age was 7 days (IQR 3-13), 70% were male. Bilious vomiting was green (13/27; 48%), yellow (9/27; 33%), or both (5/27;19%). All had an ultrasound performed, and it was diagnostic in 24 (80%). Seven (23%) had upper gastrointestinal series performed; all were diagnostic. Median time between arrival and ultrasound was 146 min (IQR 62-234), and between arrival and surgery (Ladd's procedure) was 297 minutes (IQR 206-368).

Conclusions: In our cohort, midgut volvulus had a mortality rate of 2/30 (7%). Bilious vomiting, which can be either green and/or yellow, is a reliable clinical sign of midgut volvulus in infants. Ultrasound has good diagnostic accuracy. Delay of definitive surgery was considered high with potential for improvement at different timepoints. These timepoints were targeted in the development of a clinical practice guideline to reduce delays in the management of infants with bilious vomiting.