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Table of Contents   
ORIGINAL ARTICLE
Year : 2023  |  Volume : 28  |  Issue : 6  |  Page : 493-496
 

Appendectomy in management of malrotation of gut is it necessary?


1 Department of Anatomy, RML, Lucknow, Utter Pradesh, India
2 Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Utter Pradesh, India
3 Department of Pediatric Surgery, Kailash Deepak Hospital, New Delhi, India

Date of Submission12-May-2023
Date of Decision15-Jul-2023
Date of Acceptance29-Jul-2023
Date of Web Publication02-Nov-2023

Correspondence Address:
Vijai Datta Upadhyaya
Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow - 226 014, Utter Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_108_23

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   Abstract 


Introduction: Malrotation is a congenital anatomical anomaly that affects the normal positioning of the intestines. Traditional management of malrotation, as described by Ladd, consists of detorsion of the volvulus if present, division of Ladd's bands, widening of the mesenteric root, proper positioning of the small and large bowels, and a prophylactic appendectomy. This study was done to determine whether appendectomy should be an integral part of the Ladds procedure or if it can be avoided.
Materials and Methods: This retrospective observational study was conducted in one pediatric surgical unit in the tertiary care center of North India. All the cases of malrotation of the gut managed from January 2008 to December 2018 were reviewed. The details of the patients were recovered from the electronic data recording system of the hospital and manual operation theater records. The cases that have a follow-up of <5 years were not included in the study. The details were charted in an Excel Sheet for the analysis. No statistical test was performed because there was no event in patients in whom prophylactic appendectomy was not done.
Results: The data analysis revealed that a total of 66 malrotation patients were managed during this period, those who fulfilled the inclusion criteria. Among 66 cases included in the study, in 41 cases, prophylactic appendectomy was done, whereas in the rest 25, prophylactic appendectomy was not done. During the follow-up, none of the patients in whom the appendix was preserved presented with signs or symptoms related to appendicitis or any other complications.
Conclusion: Ladds procedure without appendectomy can be performed in view of the potential use of the appendix in the future, and with the fact that in the current era of advanced medicine, appendicitis can be diagnosed early due to the advancement of imaging and better record keeping.


Keywords: Ladds procedure, MACE, obstruction appendicitis


How to cite this article:
Sthapak E, Kanneganti P, Upadhyaya VD, Kumar B, Agarwal N, Mishra A. Appendectomy in management of malrotation of gut is it necessary?. J Indian Assoc Pediatr Surg 2023;28:493-6

How to cite this URL:
Sthapak E, Kanneganti P, Upadhyaya VD, Kumar B, Agarwal N, Mishra A. Appendectomy in management of malrotation of gut is it necessary?. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Nov 28];28:493-6. Available from: https://www.jiaps.com/text.asp?2023/28/6/493/389309





   Introduction Top


Malrotation is one of the common malformations of the gastrointestinal (GI) tract and is related to the anomalies of intestinal rotation and fixation. Various anatomic descriptions have been given to the malrotation variants, including incomplete rotation, atypical malrotation, mixed rotation, and complete malrotation.[1] It is one of the most frequently encountered surgical emergencies in pediatric patients. Most of the cases present within 1 year of life, and the majority is diagnosed within 1 month of life. Presentation after this period is relatively uncommon and a majority of these are incidental findings. Diagnosis is suspected clinically, which is usually supported by the presence of reversal of superior mesenteric artery and vein (SMA/SMV) relation and of the whirlpool sign on ultrasound, which indicates twisting of the mesenteric vessel in case of volvulus or by upper GI contrast study. Contrast-enhanced computed tomography (CT) of the abdomen may be required for diagnosis, especially in older children.

Malrotation of the gut requires urgent treatment because of its dreadful complications. The management of malrotation was initially described by Ladd and it consists of detorsion of the volvulus if present, division of Ladd's bands, widening of the mesenteric root, proper positioning of the small and large bowels, and a prophylactic appendectomy.[2]

Appendectomy was performed in classical Ladd procedure because of the following reason:[3]

  1. The placement of the appendix in the left upper quadrant would make future diagnosis of acute appendicitis delayed or sometimes missed
  2. The dissection of the Ladd's bands may cause damage to the appendiceal vessels supplying the appendix.


However, with advancements in data management, record keeping, improved imaging, and the gain of clinical experience overtime, the need for doing appendectomy in the Ladd's procedure is being questioned. This study was conducted to assess the need for appendectomy in the cases of malrotation of the gut.


   Materials and Methods Top


This study was done to observe whether leaving the appendix in situ during Ladd's procedure is feasible or not, second should preserving the appendix can be recommended against the classical teaching of performing prophylactic appendectomy in cases of Ladd's procedure.

This retrospective observational study was conducted in one pediatric surgical unit of the tertiary care center of North India. This study was planned because one surgeon in the unit was not doing the prophylactic appendectomy routinely in the cases of Ladd's procedure for malrotation of the gut, whereas another consultant in the unit was doing prophylactic appendectomy. All the cases of malrotation of the gut managed from January 2008 to December 2018 were reviewed. The details of the patients were recovered from the electronic data recording system of the hospital and manual operation theater records. The details were charted in an Excel sheet for analysis.

Inclusion criteria

  1. The patients diagnosed to have malrotation of the bowel are diagnosed either on ultrasound, contrast study, or CT scan
  2. Incidentally diagnosed case of malrotation
  3. Follow-up of at least 5 years to a maximum of 10 years.


Exclusion criteria

  1. The patients operated outside our hospital
  2. The appendix was found to be pathological or perforated at the time of surgery
  3. The patients whose follow-up for a minimum of 5 years was not over.


The parameter recorded for each case includes age, sex, and whether appendectomy was done at the time of surgery or not. The follow-up records were also reviewed for the presence of any complications attributable to the appendix in the follow-up period. In follow-up, patients were observed for occurrence of appendicitis presenting as acute appendicitis, appendicular perforation with peritonitis, appendicular abscess, and appendicular lump formation.

The data were collected from January 2009 to December 2019. The details were incorporated into the Microsoft Excel sheet. No statistical analysis was done in this study because there was no event.


   Results Top


The data analysis revealed that a total of 66 malrotation patients were admitted during this period who fulfilled the inclusion criteria. Among these 66 patients, the association with choledochal cysts was noted in five patients. The study revealed that there were 18 females and 48 males, with a sex ratio of M:F = 2.7:1. The age ranged from as early as 4 days of life to 17 years of age [Table 1]. Presentation varied according to age. Those presented in the neonatal period or infancy had bilious vomiting as the most common symptom and those presented after infancy, the most common symptom was intermittent pain, growth failure, or they were incidentally found to have the condition on investigations done for some other indication. Whirlpool sign and inversion of the SMA/SMV axis were the most common parameter for diagnosis, and the decision to proceed with the surgery was made in addition to symptomatology and clinical examination.
Table 1: Patient profile as per their age of presentation in different group

Click here to view


In our study, we noted that a total of 41 patients underwent Ladd's procedure with appendectomy and 25 without appendectomy. Parents of those who underwent Ladd's procedure without appendectomy were informed about the possible risk of appendicitis in the future and details about the new position of the appendix and symptoms related to appendicitis. Around 28% of patients had volvulus, but none of them had gangrenous or pregangrenous changes.

All patients were followed up for a minimum of 5 years to a maximum of 10 years as per the protocol of our institute. At the time of follow-up, questionnaires related to appendicitis were asked and documented followed by re-enforcing details regarding possible attacks of appendicitis in the future in the cases where prophylactic appendectomy was not done.

During the follow-up, none of the patients in whom the appendix was preserved presented with signs or symptoms related to appendicitis. In our study, we did not come across any patient in Ladd's procedure without an appendectomy arm presenting with any of the complications relating to the appendix. Given the observations made in our study and various studies supporting the utility of the appendix, leaving the appendix in situ during Ladd's procedure for malrotation may be the new standard in the surgical management of malrotation.


   Discussion Top


The controversy regarding performing Ladd's procedure with or without an appendectomy remains unclear. This is partly attributed to the lack of evidence and available literature in assessing the benefits and risks of performing the procedure without an appendectomy. While there was no single study that analyzed the risks and benefits of performing Ladd's procedure without an appendectomy, some of the aforementioned studies stated that there were cases of Ladd's procedure performed without an appendectomy.[4],[5],[6] However, there was neither mention of the clinical reasoning nor is there any available data on long-term follow-up of these patients, but in the current study, patients were followed a minimum of 5-year postsurgery and a maximum period of follow-up is 14 years.

The primary reason why the prophylactic appendectomy was not done in the present study was the potential use of the appendix in the future. Conventionally, the appendix has been considered a vestigial organ with no known function attributed to it. With the advancements in medical research, it is not appropriate to level the appendix as a vestigial organ. A well-established use of the appendix is as a surgical conduit in the Mitrofanoff procedure[7] and Malone antegrade colonic enema (MACE).[8]

Second, the appendix has been found to be the abode of a variety of protective commensal microbiota. These commensal residents act as a source of replenishment of gut-friendly bacteria which are lost during diarrheal illnesses or in the presence of pathogenic bacteria. The appendix is also a niche of lymphoid tissue and a source of IgA antibodies. Although most postappendectomy patients continue to live asymptomatic life, equally true has been the proven correlation between ulcerative colitis, recurrent Clostridium difficile infection, and some myocardial or inflammatory illnesses. It has been proven that the removal of the appendix contributes to the alteration of the gut microbiota into a less diverse microbiome.[9],[10]

The third reason for avoiding prophylactic appendectomy was the fact that appendectomy was found to be associated with increasing the potential risk of developing diseases, such as GI cancer, rheumatoid arthritis, sarcoidosis, Parkinson's disease, pyogenic liver abscess, and gallstone formation.[11],[12]

Another reason for not doing prophylactic appendectomy in cases of malrotation of the gut was the fact it serves as a stem cell reservoir in which mesenchymal stem cells have been identified and isolated from human vermiform appendices.[13] Another important aspect of doing incidental appendectomy is the theoretical risk of converting a clean procedure into a clean contaminated one.

Concerning Ladd's procedure, incidental appendectomy traditionally has been recommended mostly for the reason that at the time of inception of the procedure, the imaging technology was in its infancy and there was a limited experience in symptomatology and clinical signs of appendicitis in its new home that is; the left upper abdomen second the documentation was not proper, especially in second world countries. With growing clinical experience and advancements in imaging technology, along with the fact that operative notes mentioning the position of the appendix placed at the new home, the utility of incidental appendectomy has been questioned.

In our study, the maximum follow-up was 14 years and we did not encounter any case with appendix-related complications, in those patients who underwent Ladd's procedure without appendectomy. The new imaging techniques, both ultrasound and CT scanning, are very much capable of detecting appendix-related issues even in new after Ladd's procedure, and with the growing use of laparoscopy, which can be both diagnostic and therapeutic for appendix-related issues post-Ladd's procedure, it becomes imperative to leave the appendix in situ.

The future always remains full of uncertainties and newer research may come up highlighting the importance of the current vestigial organ. Moreover, an appendix may find utility in surgical procedures in addition to what is known today, and new associations with medical illnesses too, can come up. The organ in ensuing studies and the future may be found to be more beneficial than what is currently known.


   Conclusion Top


Our study supports the concept of leaving the appendix in situ during Ladd's procedure for malrotation because of its potential use in the future. Although the evidence and available literature that assess the benefits and risks of not performing an appendectomy with Ladd's procedure are not yet firmly established. Ladd's procedure without appendectomy may be considered the new gold standard in the surgical management of the malrotation although a proper multicentric randomized clinical trial is needed for substantial evidence.

  • Weakness: It is a retrospective observational study, second being a tertiary center; the number of such cases is very limited at our center
  • Strength: Long follow-up and good recordkeeping.


Acknowledgment

All residents, staff, technicians, patients, and parents for their help and cooperation during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
McVay MR, Kokoska ER, Jackson RJ, Smith SD. Jack Barney award. The changing spectrum of intestinal malrotation: Diagnosis and management. Am J Surg 2007;194:712-7.  Back to cited text no. 1
    
2.
Ladd WE. Gross RE. Intestinal obstruction resulting from malrotation of the intestines and colon: Philadelphia In: Ladd WE, Gross RE. Abdominal Surgery of Infancy and Childhood. WB Saunders 1941: p.134-7.  Back to cited text no. 2
    
3.
Badea R, Al Hajjar N, Andreica V, Procopeţ B, Caraiani C, Tamas-Szora A. Appendicitis associated with intestinal malrotation: Imaging diagnosis features. Case report. Med Ultrason 2012;14:164-7.  Back to cited text no. 3
    
4.
Arnaud AP, Suply E, Eaton S, Blackburn SC, Giuliani S, Curry JI, et al. Laparoscopic Ladd's procedure for malrotation in infants and children is still a controversial approach. J Pediatr Surg 2019;54:1843-7.  Back to cited text no. 4
    
5.
Saberi RA, Gilna GP, Slavin BV, Cioci AC, Urrechaga EM, Parreco JP, et al. Outcomes for Ladd's procedure: Does approach matter? J Pediatr Surg 2022;57:141-6.  Back to cited text no. 5
    
6.
da Costa KM, Saxena AK. Laparoscopic Ladd procedure for malrotation in newborns and infants. Am Surg 2021;87:253-8.  Back to cited text no. 6
    
7.
Veeratterapillay R, Morton H, Thorpe AC, Harding C. Reconstructing the lower urinary tract: The Mitrofanoff principle. Indian J Urol 2013;29:316-21.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Malone PS, Ransley PG, Kiely EM. Preliminary report: The antegrade continence enema. Lancet 1990;336:1217-8.  Back to cited text no. 8
    
9.
Girard-Madoux MJ, Gomez de Agüero M, Ganal-Vonarburg SC, Mooser C, Belz GT, Macpherson AJ, et al. The immunological functions of the appendix: An example of redundancy? Semin Immunol 2018;36:31-44.  Back to cited text no. 9
    
10.
Cai S, Fan Y, Zhang B, Lin J, Yang X, Liu Y, et al. Appendectomy is associated with alteration of human gut bacterial and fungal communities. Front Microbiol 2021;12:724980.  Back to cited text no. 10
    
11.
Chung SD, Huang CC, Lin HC, Tsai MC, Chen CH. Increased risk of clinically significant gallstones following an appendectomy: A five-year follow-up study. PLoS One 2016;11:e0165829.  Back to cited text no. 11
    
12.
Sawahata M, Nakamura Y, Sugiyama Y. Appendectomy, tonsillectomy, and risk for sarcoidosis – A hospital-based case-control study in Japan. Respir Investig 2017;55:196-202.  Back to cited text no. 12
    
13.
De Coppi P, Pozzobon M, Piccoli M, Gazzola MV, Boldrin L, Slanzi E, et al. Isolation of mesenchymal stem cells from human vermiform appendix. J Surg Res 2006;135:85-91.  Back to cited text no. 13
    



 
 
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