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Intestinal nonrotation is the most common type of mid-gut anomaly where the small bowel predominantly occupies the right side of the peritoneal cavity, while the colon primarily resides on the left. The occurrence of acute appendicitis in mid-gut anomalies poses a serious diagnostic challenge due to unprecedented clinical and imaging features. Here we present a 20-year-old female who came to the hospital with left lower abdominal pain of 3 weeks duration, referred with a diagnosis of tubo-ovarian abscess. Further evaluation with an abdominopelvic CT scan revealed ileocecal junction in the left lower quadrant with a well-defined appendiceal abscess. The absence of a prior diagnosis of nonrotation, combined with the atypical presentation of pain, complicates the diagnosis of appendicitis. We emphasize the significance of considering left-sided appendicitis as a potential diagnosis for left-sided abdominal pain and recommend early cross-sectional imaging to prevent complications and improve surgical outcomes.

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Intestinal malrotation (IM), a rare congenital anomaly disrupting typical embryonic rotation around the superior mesenteric artery, is exceptionally uncommon in adults, with its link to colon cancer being even rarer. This article presents a case of colonic cancer in conjunction with IM in a 63-year-old male. Image studies and intraoperative findings show signs of IM. Open resection was performed due to concerns about vascular anomalies and abnormal lymphatic drainage. The case underscores the rarity of colon cancer in a malrotated gut, highlighting the necessity of preoperative identification for precise surgical planning and emphasizing the importance of careful dissection to prevent inadvertent vascular injury.

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Intestinal malrotation is typically encountered in the first year of life and is rarely seen in adult populations. Herein, we present the case of a 48-year-old woman with a surgical history of laparoscopic Nissen-sleeve gastrectomy before 11 months who was referred to the general surgery service after presenting to the emergency department with acute epigastric abdominal pain for one-day duration. Radiography and a computed tomography (CT) scan of the abdomen revealed a large pneumoperitoneum. Subsequently, a diagnostic laparoscopy was performed, which detected a sealed perforation in the fundus of the wrapped-sleeved stomach, along with an incidental finding of intestinal malrotation. The encountered variation of anatomy created an intraoperative challenge during the conversion from Nissen-Sleeve gastrectomy to single anastomosis gastric bypass. The diagnosis of intestinal malrotation in adults is often overlooked, posing substantial diagnostic and management challenges when encountered.

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Intestinal nonrotation is a subtype of malrotation occurring when the midgut fails to rotate before returning to the peritoneal cavity between weeks 8-10 of development. Though sometimes presenting as volvulus during the neonatal period, a subset of patients remains asymptomatic and are identified incidentally as adults. When patients with intestinal nonrotation present with abdominal symptoms, there exists a diagnostic dilemma for the treating surgeon. We present the case of a patient who presented with acute abdominal pain and vomiting, with radiographic findings of intestinal nonrotation and no other acute pathology. Symptoms spontaneously resolved with conservative management for likely etiology of viral gastroenteritis. At the one-month follow-up, the patient had no residual or recurrent symptoms, with no further interventions planned.

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Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly. Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations. Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

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The kidneys and ureters are retroperitoneal structures in the upper part of the paravertebral gutters, tilted against the structures on the sides of the lowest two thoracic and upper three lumbar vertebrae, so that their anterior and posterior surfaces face antero-laterally and postero-medially, respectively. Congenital anomalies of the urinary tract are often the underlying cause of renal pathologies; 40% of these pathological conditions are due to variations in location, shape, and size of the kidney(s), calyces, ureter, or bladder. This case report describes the presence of a unilateral non-rotated left kidney with vascular and ureter variations found during routine cadaveric dissection for medical graduates. Alterations in rotation of the kidney and its relation to structures at the hilum have great clinical significance when conducting surgical procedures like partial nephrectomy, nephron sparing surgery, and renal transplantation.

Os rins e o ureter são estruturas retroperitoneais localizadas na parte superior do sulco paravertebral, inclinados contra as estruturas laterais das duas vértebras torácicas inferiores e das três vértebras lombares superiores. Assim, as superfícies anteriores e posteriores estão nas porções anterolateral e posteromedial, respectivamente. As anomalias congênitas do trato urinário frequentemente são causas subjacentes de patologias renais, e 40% delas ocorrem devido a variações no local, formato e tamanho dos rins, cálices, ureter ou bexiga. Este relato de caso descreve a presença de rim esquerdo unilateral sem rotação com variações vasculares e de ureter encontradas durante uma dissecção de cadáver rotineira com graduandos de Medicina. As alterações na rotação do rim e a sua relação com as estruturas no hilo têm grande importância clínica durante procedimentos cirúrgicos como a nefrectomia parcial, a cirurgia poupadora de néfrons e o transplante renal.

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BACKGROUND: Malrotation of the bowel refers to any variation in the rotation and fixation of the gastrointestinal tract during the first trimester and is most commonly detected postnatally. Nonrotation of the bowel and incomplete rotation of the bowel are subtypes of malrotation. OBJECTIVE: To determine if the nonrotation subtype of malrotation of the bowel can be detected on prenatal magnetic resonance imaging (MRI). MATERIALS AND METHODS: Cases from 2012 to 2018 with nonrotation of the bowel without obstruction confirmed by imaging, surgery and/or autopsy were compared to prenatal imaging. Prenatal imaging was retrospectively reviewed to determine if prenatal diagnosis of malrotation could be made. Exclusion criteria included diaphragmatic hernia, omphalocele and gastroschisis. RESULTS: Ten cases of nonrotation diagnosed postnatally by upper gastrointestinal series (upper GI)/small bowel follow-through (SBFT) or autopsy had prenatal MRI. Prenatal MR studies were performed for assessment of heterotaxy syndrome with congenital heart disease (6/10), congenital heart disease with additional anomalies (suspected VACTERL [vertebral, anorectal, cardiac, tracheoesophageal, renal, limb] and suspected lung agenesis, ventriculomegaly) (3/10) and skeletal dysplasia (1/10). Eight upper GI/SBFT cases demonstrated nonrotation of the bowel without obstruction with the small bowel completely on one side of the abdomen contralateral to the stomach and the colon ipsilateral to the stomach; four cases were confirmed by surgery. The small bowel in one upper GI/SBFT case was unilateral contralateral to the stomach with a meandering colon. One case had nonrotation diagnosed at autopsy. There were no cases of postnatal midgut volvulus. Retrospective review of the 10 cases had prenatal MRI performed between 23 and 37 weeks of gestation. The coronal plane was the most optimal plane to assess the position of the stomach, small bowel and colon in relationship to each other. The small bowel was best assessed on T2-weighted images while the colon was best assessed on T1-weighted images. A nonrotated position of the small bowel was present in all 10 fetal MRI cases mirroring postnatal findings, with the small bowel contralateral to the stomach in 9/10 cases and ipsilateral to the stomach (in the right abdomen) in 1/10 cases. The colon was visualized by prenatal MRI in 9/10 cases, with 1 case limited due to a lack of T1-weighted imaging. A nonrotated position of the colon contralateral to the small bowel was present in 7/9 cases. In 2/9 cases, the colon was wandering, positioned on both sides of the midline. Colonic position in all nine cases matched postnatal findings. No cases presented with prenatal bowel obstruction. CONCLUSION: Detection of nonrotation of the bowel is possible on prenatal MRI.

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There are some incidental findings during bariatric surgery. Some of these findings may make the operation more challenging than routine surgery. Intestinal malrotation/non-rotation are rare congenital anomalies that may remain asymptomatic until bariatric surgery. Here we report a 30-year-old female patient with unknown intestinal congenital anomaly which was diagnosed during surgery and she underwent Roux-en-Y gastric bypass, which can be a challenging procedure in intestinal malrotation/non-rotation and conversion may be needed.

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Abstract The kidneys and ureters are retroperitoneal structures in the upper part of the paravertebral gutters, tilted against the structures on the sides of the lowest two thoracic and upper three lumbar vertebrae, so that their anterior and posterior surfaces face antero-laterally and postero-medially, respectively. Congenital anomalies of the urinary tract are often the underlying cause of renal pathologies; 40% of these pathological conditions are due to variations in location, shape, and size of the kidney(s), calyces, ureter, or bladder. This case report describes the presence of a unilateral non-rotated left kidney with vascular and ureter variations found during routine cadaveric dissection for medical graduates. Alterations in rotation of the kidney and its relation to structures at the hilum have great clinical significance when conducting surgical procedures like partial nephrectomy, nephron sparing surgery, and renal transplantation.

Resumo Os rins e o ureter são estruturas retroperitoneais localizadas na parte superior do sulco paravertebral, inclinados contra as estruturas laterais das duas vértebras torácicas inferiores e das três vértebras lombares superiores. Assim, as superfícies anteriores e posteriores estão nas porções anterolateral e posteromedial, respectivamente. As anomalias congênitas do trato urinário frequentemente são causas subjacentes de patologias renais, e 40% delas ocorrem devido a variações no local, formato e tamanho dos rins, cálices, ureter ou bexiga. Este relato de caso descreve a presença de rim esquerdo unilateral sem rotação com variações vasculares e de ureter encontradas durante uma dissecção de cadáver rotineira com graduandos de Medicina. As alterações na rotação do rim e a sua relação com as estruturas no hilo têm grande importância clínica durante procedimentos cirúrgicos como a nefrectomia parcial, a cirurgia poupadora de néfrons e o transplante renal.

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BACKGROUND: A combination of intestinal malrotation and distal cholangiocarcinoma is considered a rare condition and poses some difficulties in surgical management. We present a case of a patient with asymptomatic nonrotation of the midgut with a concomitant distal cholangiocarcinoma who underwent successful pancreaticoduodenectomy. CASE PRESENTATION: A 52-year-old Sudanese man presented to our hospital with progressive painless jaundice associated with dark urine, pale stool, and itching for the last 2 months. He had no other complaint or significant previous medical history apart from being an ex-smoker. His clinical examination revealed a palpable gallbladder and scratch mark. His other systems were unremarkable. His blood test results showed a normal complete blood count, elevated total bilirubin (mainly direct bilirubin), elevated alkaline phosphatase, and normal cancer antigen 19-9 and carcinoembryonic antigen. Ultrasound, computed tomography of the abdomen, and magnetic resonance cholangiopancreatography showed a dilated intrahepatic and extrahepatic biliary system down to the distal part, where the lumen was obstructed by a periampullary mass measuring 2.4 by 2.1 cm. The patient's gallbladder was distended. He had no liver metastases or ascites and few lymph nodes. Inversion of the superior mesenteric artery and superior mesenteric vein but no invasion was seen, and malrotation of the bowel was observed with the large bowel on the left side and the small bowel to the right of the abdomen. Endoscopic retrograde cholangiopancreatography showed a fleshy ampulla that was stented. Laparotomy showed malrotation, with the duodenum straight on the right side of the midline, and Ladd's band crossed the second portion of the duodenum. The vessels were approached from the lateral side meticulously after kocherization of the duodenum and pancreas, dissection along an extended portion of the superior mesenteric artery to assure preservation of the superior mesenteric artery and branches going to the jejunum, Ladd's procedure, division of the jejunum 10 cm below the uncinate process of pancreas, and modified pancreaticoduodenectomy were performed, and anastomoses were performed in the standard fashion. The patient had an uneventful postoperative course, started oral feeding after 5 days, and discharged to home on day 10 for regular follow-up. Histopathology confirmed distal cholangiocarcinoma, and the patient was referred for further oncological management. CONCLUSIONS: Pancreaticoduodenectomy can be safely performed in patients with intestinal malrotation with some modifications of the standard approach. Meticulous dissection after preoperative identification of vascular anomaly and a lateral approach are of great help to reduce morbidity.

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BACKGROUND: Intestinal nonrotation is a rare congenital condition that causes fatal colonic volvulus at any age. Once volvulus attack occurs, radical surgical therapy is required for treatment and the prevention of recurrence. This report describes the case of an adult female patient with a recurrence of cecum volvulus due to intestinal nonrotation after transverse colon resection for colonic volvulus. CASE PRESENTATION: A 27-year-old female visited our emergency room (ER) with intermittent abdominal pain and nausea. Enhanced computed tomography (CT) showed enlargement of the level of the ascending and transverse colon and an obstruction with a whirlpool sign at the transverse colon. The small intestine was distributed on the right side of the abdominal cavity, and the large intestine occupied the left side. She was diagnosed with volvulus with intestinal nonrotation, and emergency surgery was performed. Surgical examination indicated that the ascending colon to the transverse colon was not fixed to the retroperitoneum, and the transverse colon was rotated 180° clockwise. The axis of the volvulus was a mesenteric adhesion of the transverse colon. The involved transverse colon was resected, and the intestine was reconstructed by functional end-to-end anastomosis (FEEA). Six years after the initial surgery, the patient presented to the ER with abdominal fullness and lower abdominal pain. Enhanced CT revealed that the cecum, ascending colon, and remaining transverse colon were dilated with an obstruction. The appendix was located in the left upper abdominal cavity. The clinical diagnosis was cecal volvulus with intestinal nonrotation. An emergency laparotomy revealed that the cecum was rotated 180° clockwise. The terminal ileum to the remaining transverse colon was resected, and FEEA was performed. Seven months later, she suffered obstruction of the intestine caused by an operative adhesion, and conservative treatment was successful. The patient has had no abdominal symptoms for one and a half years so far. CONCLUSIONS: Surgeons should realize that nonrotation of the intestines induces volvulus in adulthood and should familiarize themselves with its clinical findings, appropriate treatment, and prognosis. Even after surgical treatment, awareness of the recurrence of volvulus should be maintained to avoid a late diagnosis.

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PRESENTATION OF CASE: A multiparous expectant mother was referred to our tertiary unit at 23 weeks with a complex fetal cardiac anomaly in the context of suspected heterotaxy syndrome. The cardiac findings were consistent with isomerism: the fetal cardiac position was levocardia with a single functioning double outlet ventricle and AV valve, pulmonary stenosis, and interrupted inferior vena cava (IVC) with azygous continuation. The fetal abdominal situs was also altered, with the stomach to the right, and the hepatobiliary system midline to left. The spleen was not identified antenatally or postnatally. At 36 weeks, ultrasound revealed an abnormal bowel pattern with small bowel loops on the right side of the abdomen and large bowel on the left, suggesting a diagnosis of non- rotation. The infant was delivered vaginally at 39 weeks. The cardiac diagnosis and non-rotation of the small bowel were confirmed by postnatal echocardiography and contrast fluoroscopy. DISCUSSION: Heterotaxy syndrome is traditionally classified into right or left isomerism depending on how and where the organs are anatomically arranged. The case presented here demonstrates mixed laterality and prenatal ultrasound features of non-rotation. CONCLUSION: It is important to be informed of the embryological variants of isomerism and actively seek antenatal evidence of bowel non-rotation in such cases.

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BACKGROUND: An incidental finding of intestinal nonrotation at the time of bariatric surgery poses the following 2 dilemmas: (1) which operation to perform, and (2) whether an appendectomy should be performed concurrently. OBJECTIVES: To review the experience of 2 Bariatric Centers of Excellence with laparoscopic sleeve gastrectomy (LSG) in patients with intestinal nonrotation, and to perform a systematic review of the literature on this topic. SETTING: Two Bariatric Centers of Excellence as designated by the Ontario Bariatric Network. METHODS: A chart review of all LSG cases performed in patients with intestinal nonrotation at 2 centers was performed. A systematic review on performing bariatric surgery in patients with intestinal nonrotation/malrotation was conducted using EMBASE and MEDLINE databases. RESULTS: Four patients (.4% of all cases) underwent LSG in the setting of intestinal nonrotation. Two patients underwent a concurrent appendectomy. Three patients developed postoperative gastrointestinal reflux disease and 1 patient required conversion to a laparoscopic Roux-en-Y gastric bypass. A total of 12 retrospective studies with 23 patients were included in the systematic review. Nineteen patients underwent Roux-en-Y gastric bypass, 3 patients underwent a duodenal switch, and 1 patient underwent LSG. Nine patients (41%) underwent a concurrent appendectomy. Reasons cited for not performing an appendectomy include not completely understanding the anatomic defect, being surprised by the discovery of nonrotation, no consent for the procedure, and suboptimal trocar placement for an appendectomy. CONCLUSIONS: LSG is a reasonable alternative to laparoscopic Roux-en-Y gastric bypass in patients with intestinal nonrotation. A concurrent appendectomy may not be necessary in the era of modern cross-sectional imaging for diagnosing acute appendicitis.

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PURPOSE: The gold standard for the diagnosis of malrotation is barium contrast study of the upper gastrointestinal system (UGCS), while color Doppler ultrasonography (CDUS) is another method used in the diagnosis. We investigated the value of CDUS for the diagnosis of malrotation in this study. METHODS: UGCS images, CDUS images, plain abdominal images, demographic data, and symptoms of 82 patients who were investigated for presumed malrotation during a 7-year period were evaluated, retrospectively. RESULTS: All patients underwent CDUS, and 18% of these patients were diagnosed with malrotation as the superior mesenteric vein was seen to be on the left of the superior mesenteric artery. We found that 16% of the 75 patients who underwent UGCS were diagnosed with malrotation. The sensitivity and specificity of CDUS in the diagnosis of malrotation was found to be 93.8 and 100%, respectively. The respective values for UGCS were 91.7 and 98.4%. CONCLUSION: Current data in the literature and our results underline that UGCS may yield false-positive and false-negative results. Although CDUS was found to be a reliable method for the diagnosis of malrotation in our study, the limitations of UGCS are also recognized for CDUS. Prospective studies are needed to determine the more valuable method.

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Rotation abnormalities may be asymptomatic or may be associated with obstruction caused by bands, midgut volvulus, or associated atresia or web. The most important goal of clinicians is to determine whether the patient has midgut volvulus with intestinal ischemia, in which case an emergency laparotomy should be done. If the patient is not acutely ill, the next goal is to determine whether the patient has a narrow-based small bowel mesentery. In general, the outcomes for children with a rotation abnormality are excellent, unless there has been midgut volvulus with significant intestinal ischemia.

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Right paraduodenal hernia usually occurs in setting of nonrotated small bowel, when small bowel herniates through Waldeyer's fossa (a defect in the first part of jejunal mesentery). It lies behind the superior mesenteric artery and inferior to the transverse colon or third portion of duodenum. We studied two cases of right paraduodenal hernia, an incomplete rotation, and nonrotation of small bowel, respectively, and describe CT abdomen signs, which can give a preoperative diagnosis.

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INTRODUCTION: Chilaiditi's syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi's syndrome in association with intestinal malrotation and this case study describes its successful management. PRESENTATION OF CASE: An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic. DISCUSSION: In nine of the previously reported cases of Chilaiditi's syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management. CONCLUSION: Chilaiditi's syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.

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Nonrotation of intestine is a congenital abnormality of the midgut which is due to error in the process of rotation. Errors in the 2nd and 3rd stage of rotation can lead to series of abnormalities in the form of malrotation and reversed rotation. As a consequence, the relative position of other organs likes caecum, intestine, meckel's diverticulum changes. This can lead to missing diagnosis of common clinical conditions such as appendicitis. The incidence of nonrotation is 1:500. The congenital abnormality appears to be rare as this could be an incidental abnormality. The symptoms of nonrotation of intestine could be biliary vomiting, recurrent abdominal pain. This could be due to midgut volvulus and intestinal obstruction which happens as a consequence of nonrotation of the intestine. The investigations used for detection and confirmation are CT Imaging. Other associations of nonrotation of the intestine are peritoneal bands. Here we report a case of nonrotation of intestines. In the cadaver of age around 70 years, the small intestinal loops was situated in the right side of the abdominal cavity and large intestine looped on the left side of the abdominal cavity. This was also associated with aberrant position of the caecum and appendix. There were associated peritoneal bands extending from the ascending colon to the left side the abdominal wall. The bands had been removed to visualize the large intestinal loops.

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We report on the case of a 29-year-old male with acute appendicitis superimposed on the non-rotational anomaly of the gastrointestinal tract not detected on the computed tomography (CT) scan but correctly diagnosed on ultrasonography (US). This case suggested an additional role of US on the acute abdomen even underlying malrotation of the gastrointestinal tract.

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