title: Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Although the principles of the Ladd's procedure for intestinal malrotation in children have remained unchanged since its first description, in the era of minimally invasive surgery it is controversial whether laparoscopy is advantageous over open surgery. The aim of our study was to determine whether the surgical approach for the treatment of malrotation had an impact on patient outcome.
  
  
  METHODS
  Using a defined strategy (PubMed, Cochrane, Embase and Web of Science MeSH headings), two investigators independently searched for studies comparing open versus laparoscopic Ladd's procedure in children. Case reports and opinion articles were excluded. Outcome measures included age at operation, time to full enteral feeding, length of hospital stay, and post-operative complications. Maneuvers were compared using Fisher's exact test and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± SD.
  
  
  RESULTS
  Of 308 abstracts screened, 49 full-text articles were analyzed and nine (all retrospective) met our search criteria. Selected articles included 1003 patients, of whom 744 (74 %) underwent open surgery and 259 (26 %) laparoscopy. Patients who had open surgery were younger (0.9 ± 1.2 years) than those who underwent laparoscopy (2.6 ± 3 years; p < 0.0001). Laparoscopy was converted to open Ladd's in 25.3 % patients. Laparoscopy was associated with faster full enteral feeding (1.5 ± 0.3 days) in comparison to open surgery (4.6 ± 0.1 days, p < 0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9 ± 4.3 days) than in the open group (11.2 ± 6.7 days; p < 0.0001). Open surgery was associated with higher overall post-operative complication rate (21 %) than laparoscopy (8 %; p < 0.0001). Although there was no difference in the prevalence of post-operative bowel obstruction (open, n = 10 %; laparoscopy, n = 0 % p = 0.07), post-operative volvulus was more frequent in the laparoscopy group (3.5 %) than in the open group (1.4 %, p = 0.04).
  
  
  CONCLUSIONS
  Comparative but non-randomized studies indicate that laparoscopic Ladd's procedure is not commonly performed in young children. Although one third of laparoscopic procedures is converted to open surgery, laparoscopy is associated with shorter time to full enteral feeds and length of hospital stay. However, laparoscopic Ladd's procedure seems to have higher incidence of post-operative volvulus. Prospective randomized studies with long follow-up are needed to confirm present outcome data and determine the safety and effectiveness of the laparoscopic approach.
authors.affiliation: Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
authors.forename: Vincenzo Davide
authors.initials: VD
authors.lastname: Catania
authors.affiliation: Department of Pediatric Surgery, "Spirito Santo" Hospital, Pescara, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lauriti
authors.affiliation: Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
authors.forename: Agostino
authors.initials: A
authors.lastname: Pierro
authors.affiliation: Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada. augusto.zani@sickkids.ca.|Department of Pediatric Surgery, Sapienza University of Rome, Rome, Italy. augusto.zani@sickkids.ca.
authors.forename: Augusto
authors.initials: A
authors.lastname: Zani
mesh_terms: D002648:Child; D004065:Digestive System Abnormalities / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D045822:Intestinal Volvulus / Q000453:epidemiology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Ladd’s; Malrotation anomaly; Meta-analysis; Pediatric; Volvolus