title: Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review.
abstract: OBJECTIVE
  Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial.
  
  
  METHODS
  Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation.
  
  
  RESULTS
  There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up.
  
  
  CONCLUSIONS
  There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
authors.affiliation: Division of Pediatric General Surgery, Phoenix Children's Hospital, Phoenix, AZ. Electronic address: kgraziano@surgery4children.com.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Graziano
authors.affiliation: Division of Pediatric Surgery, University of Florida, Gainesville, FL.
authors.forename: Saleem
authors.initials: S
authors.lastname: Islam
authors.affiliation: Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH.
authors.forename: Roshni
authors.initials: R
authors.lastname: Dasgupta
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
authors.forename: Monica E
authors.initials: ME
authors.lastname: Lopez
authors.affiliation: Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center; Department of Pediatric Surgery, University of Texas Medical School, Houston, TX.
authors.forename: Mary
authors.initials: M
authors.lastname: Austin
authors.affiliation: Department of Surgery, Baylor University Medical Center, Dallas, TX.
authors.forename: Li Ern
authors.initials: LE
authors.lastname: Chen
authors.affiliation: Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, WA.
authors.forename: Adam
authors.initials: A
authors.lastname: Goldin
authors.affiliation: Division of Pediatric Surgery, Hiram C. Polk, Jr, MD; Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Cynthia D
authors.initials: CD
authors.lastname: Downard
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Albany Medical Center, Albany, NY.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Renaud
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Fizan
authors.initials: F
authors.lastname: Abdullah
mesh_terms: D058070:Asymptomatic Diseases; D002648:Child; D004386:Duodenum / Q000473:pathology; D055317:Evidence-Based Practice; D006330:Heart Defects, Congenital / Q000150:complications; D006801:Humans; D045822:Intestinal Volvulus / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D010535:Laparoscopy; D008643:Mesentery / Q000473:pathology; D011859:Radiography; D014463:Ultrasonography; D041742:Upper Gastrointestinal Tract / Q000000981:diagnostic imaging
keywords: Asymptomatic malrotation; Atypical malrotation; Diagnosis and surgical management of asymptomatic malrotation; Heterotaxy syndrome; Intestinal rotation abnormalities; Malrotation