Evidence-based medicine

1. Laparoscopic treatment of intestinal malrotation in neonates and infants: retrospective study R3 林雅慧 Int 吳舒評 指導教授：駱至誠 Evidence-based medicine

2. 我的小孩先天上有小腸轉位異常,請問醫生是傳統開腹手術比較好,還是腹腔鏡比較好呢？我的小孩先天上有小腸轉位異常,請問醫生是傳統開腹手術比較好,還是腹腔鏡比較好呢？

3. Let’s EBM !!

5. Introduction of intestinal malrotation

6. Introduction • Malrotationis incomplete rotation of the intestine during fetal development. • Mechanism • Normal situation: • The gut starts as a straight tube from stomach to rectum. • The mid bowel protrudes into the umbilical cord until it lies totally outside the abdominal cavity.

7. Introduction • As bowel rotates, the superior mesenteric arteryacts as an axis. • The duodenum, on re-entering the abdominal cavity, moves to the region of the ligament of Treitz, • The colon that follows is directed to the left upper quadrant. • The cecum subsequently rotates to lie in the right lower quadrant. • After rotation, the right and left colon and the mesenteric root become fixed to the posterior abdomen.

8. Introduction • Abdominal rotation and attachment are completed by 3 mo of gestation. • Abnormal situation: • Malrotation occurs when the bowel fails to rotate after it returns to the abdominal cavity. The 1st and 2nd portions of the duodenum are in their normal position. • The remainder of the duodenum, jejunum, and ileum occupy the right side of the abdomen while the colon is located on the left.

9. Introduction • The most common type of malrotation involves failure of the cecum to move into the right lower quadrant. • The usual location of the cecum is in the subhepatic area. • Failure of the cecum to rotate properly is associated with failure adherence to the posterior abdominal wall.

10. Introduction • Clinical manifestation • The majority of patients present in the 1st yr of life. • Patients of any age can develop acute bowel volvulus without pre-existing symptoms. • Symptoms are caused by intermittent volvulus or duodenal compression by Ladd bands affecting the small and large bowel.

11. Introduction • Symptoms: • acute or chronic obstruction • bilious emesis • recurrent abdominal pain • vomiting • malabsorption • protein-losing enteropathy

12. Introduction • Diagnosis: • Abdominal plain: nonspecific but can demonstrate duodenal obstruction with a double-bubble sign • Barium enema: demonstrates malposition of the cecum • Upper gastrointestinal series: demonstrates malposition of the ligament of Treitz • Ultrasonography: demonstrates inversion of the superior mesenteric artery and vein

13. Introduction • Surgery: • If a volvulus is present, surgery is done immediately. • The duodenum and upper jejunum are freed of any bands. • The colon is freed of adhesions and placed in the right abdomen. • The cecum in the left lower quadrant, usually accompanied by incidental appendectomy.

15. Method • Between 1984 and 2003 • 21 adult patients • A mean age of 36 years (range, 14–89years) • Analyzed using two-sample t-tests and Wilcoxon rank sum tests

16. Method

17. Result • The laparoscopic group resumed oral intake earlier than the open group (1.8 vs 2.7 days; p = 0.092) • Had a shorter hospital stay (4.0 vs. 6.1 days; p = 0.050) • Required less intravenous narcotics on postoperative day 1 (4.9vs 48.5 mg; p = 0.002) • The laparoscopic group underwent a longer operation (194 vs 143 min; p = 0.053).

18. Conclusion • The laparoscopic Ladd procedure is feasible, safe, and as effective as the standard open Ladd procedure for the treatment of adults who have intestinal malrotation without midgut volvulus. • Patients also benefit from this minimally invasive approach, as manifested by an earlier oral intake, a decreased need for intravenous narcotics, and an earlier discharge from the hospital.

20. Method • Patients • Between February 1995 and September 2009 • 45 patients • Underwent a laparoscopy for suspected intestinal malrotation.

21. Method

22. Result • Postoperative outcome • The in-hospital and 30-day mortality rates were zero. • Nine patients had postoperative complications including fever, urinary tract infection, wound infection, and sepsis.

23. Result • Postoperative outcome

24. Discussion • Several retrospective case series have shown that laparoscopic treatment of intestinal malrotation is feasible with good perioperative outcomes.

25. Discussion • One larger series of 43 children (average age, 5.7 years) shows that laparoscopy is associated with a shortened time to full feedsand a shorter hospital stay but that a significant number of patients require conversion, reoperation, or both due to postoperative volvulus.

26. Discussion • This paper results show that laparoscopy is feasible for correction of malrotation in both the neonatal and infant • In retrospect, given relatively high rate of reoperations and low rate of conversion, this paper suggest that conversion to an open procedure should be done with a low threshold when there is any doubt that an adequate result can be reached laparoscopically. Reoperations should not be performed laparoscopically.

27. Discussion • Results including recurrence of intestinal malrotation and volvulus (usually within the first 6 months), have been described in most of the aforementioned studies. • Although the long-term complications of open correction are well established, these remain to be determined for the laparoscopic procedure.

28. Discussion • This paper propose that laparoscopy is preferable when intestinal malrotation is suspected and appropriate for correction of malrotation provided a low threshold for converting to open surgery is maintained.

30. Method • A retrospective analysis of the most recent 13-y experience with the Ladd’s procedure at a single instiution was performed. • Data are expressed as mean 6 standard deviation. Comparative analysis was performed using a Student’s 2-tailed t-test, with significance defined as P ＜ 0.05.

31. Method

32. Result

33. Result • We encourage a low threshold for conversion to an open approach if there is any concern about volvulus/orientation. • This may decrease morbidity for patients who are found at operation to have a low risk of recurrent volvulus.

35. Method • From May 1994 through January of 1997 • 12 patients, aged 5 days to 4 months • Weighing 3 to 7 kg • A standard Ladd’s procedure with appendectomy was performed in all cases.

36. Result • Operative times averaged 58 minutes (35 to 120 minutes). • Feedings were started on postoperative day (POD) 1 in 10 cases and POD 2 in two cases. • Hospital stay ranged from 2 to 4 days (average, 2.2) • There were no complications.

37. Conclusion • Laparoscopic Ladd’s procedure is a safe and effective technique. • It can be performed in neonates in times equivalent to standard open techniques, and it appears to allow for earlier feeds and decreased hospital stays.

38. Analysis to papers

42. We search the papers from Medline and Pubmed

46. According to these papers, we have another choice for patients with intestinal malroration. Except open surgery, we can try laparoscopy as the treatment for better outcomes and shorter hospital stay.

48. Next time we can do better on: • Be more skilled at search papers with good evidence. • Focus on the comparison and informants (neonates and children) of what we care about, not just on the one new technique.

49. Reference • Nelson Textbook of Pediatrics 18th • Sabiston Textbook of Surgery 18th • Schwartz’s Principles of Surgery 8th