intestinal malrotation is a congenital abnormal position of the bowel within the peritoneal cavity . in cases of midgut volvulus ,
it is critical to make a diagnosis and to intervene immediately to avoid the potentially life - threatening consequence of intestinal necrosis , which in severe cases may lead to short bowel syndrome .
there is currently no gold standard for treatment of massive intestinal necrosis detected at laparotomy . in cases of midgut volvulus with extensive areas of bowel ischemia that did not recover after derotation
, a second - look operation can be attempted to identify viable intestine ; however , the basis for predicting intestinal viability has yet to be described , and viability is difficult to define .
we report a case of neonatal malrotation with midgut volvulus in which necrotic , not ischemic , bowel was preserved in second - look laparotomy . the preserved intestine , which appeared to be non - viable but had a moderate blood supply , was pathologically shown as full - thickness small bowel necrosis , distributed in a patchy fashion .
fortunately , the preserved necrotic intestine was able to regenerate ; the patient survived and performs normal daily activities .
we discuss issues regarding the management of non - viable small bowel with midgut volvulus .
a baby boy was born at term , weighing 3136 g. he did well for the first ten days of life ; feeding was begun at 8 hours of age , and was well tolerated .
he vomited several times on the tenth day , presenting the next day with persistent bilious vomiting at the emergency room of the municipal hospital .
he was immediately intubated and resuscitated for pre - shock status , with initial laboratory findings of profound dehydration and marked metabolic acidosis ( ph 6.879 , be 25.8 ) .
abdominal ultrasonography and computed tomography suggested midgut volvulus with ischemic bowel . at emergent laparotomy ( fig .
1a ) , a 630 clockwise volvulus of the midgut was found with an extensive area of ischemic and dusky - black bowel from the duodenum to the transverse colon .
after derotation and ladd procedure , ischemic bowel between the distal part of the duodenum and the jejunum showed no improvement and was resected .
the distal 75 cm of the terminal ileum , which was considered to have questionable recovery of blood flow , was preserved in the hope of regenerating viable intestine .
the duodenostomy was completely necrotized but the proximal portion had maintained blood flow , and was divided , lying as a blind end in the sub - hepatic position .
blood flow in the bowel between the ileum and transverse colon was markedly improved ; however , the ileum had many necrotic areas , identifiable as paper - thin intestine , distributed in a patchy and circumferential manner ( fig .
a portion of paper - thin ileum was resected circumferentially by approximately 3 cm in width as specimen or intraoperative rapid histological diagnosis in order to determine the appropriate surgical plan .
the distribution of these apparently non - viable and necrotic areas with a moderate blood supply was so widespread that we could not resect any other part of the intestine , and made the decision to wait and see .
the resected ileum was anastomosed in an end - to - end manner and ileostomy was performed .
after the second operation , ileostomy appeared viable and the patient s general condition had improved .
aspirated gastric and bile juice to which was added a large amount of l - glutamine was administered through the ileostomy to the residual ileum and colon to confer mucosal immunity and reformation .
contrast study of the gastrointestinal tract through the ileostomy on pod 25 showed poor peristalsis and varying ileal caliber .
a small quantity of milk was then introduced through the ileostomy in addition to transparenteral nutrition ( tpn ) ; however , his body weight did not increase successfully . on pod 43 , closure of the ileostomy
pathological study showed that the appearance of the ileal mucosa had returned to normal , although the muscle layers were damaged locally . on the fourth day after closure , oral intake and
probiotics were started in addition to tpn ; there were no problems with the nutrient intake and the patient s body weight increased .
he was discharged from the hospital at 3 months of age , weighing 4626 g and tolerating oral feeding .
the survival rate of children with malrotation due to midgut volvulus is greater than 80% ; however , high mortality is still observed in patients with extensive necrotic bowel due to malrotation .
the high mortality is due to the conventional management of patients with significant non - viable bowel by extensive resection , which may lead to life - threatening short bowel syndrome .
extensive resection of the bowel remains a highly morbid condition , and has poor short- and long - term survival .
our operational goal is to derotate the midgut , perform revascularization , assess bowel viability , and resect necrotic bowel .
a second - look operation has been suggested to define areas of nonviable intestine and to improve decision - making .
second - look laparotomy may be justifiable on initial surgery findings that include extensive areas of ischemic bowel , ambiguous margins of demarcation between well - vascularized and necrotic bowel , questionable viability of the bowel , and poor blood supply to the remaining bowel .
we experienced a case of catastrophic neonatal midgut volvulus that underwent a second - look laparotomy .
the first assessment showed extensive ischemic bowel , with no further improvement after derotation and division of ladd s band . at second - look laparotomy
, the remaining small bowel appeared to be non - viable but had a moderate blood supply , and was pathologically shown to exhibit full - thickness small bowel necrosis with patchy distribution .
resection of all of the necrotic intestine would have left very little remaining small bowel .
the decision was made not to resect any intestine in the hope that the tissue would regenerate .
we concluded that the bowel was non - viable and necrotic based on its paper - thin appearance .
this diagnosis was confirmed by pathological examination ; however , the preserved intestine was able to regenerate , and normal function was restored over a period of 1 month .
necrotic bowel with a patchy distribution may offer an ideal scaffold for intestinal regeneration if there is a sufficient blood supply . from this viewpoint ,
even when intestinal viability is questionable , preservation is worthwhile in the hope of regeneration , if there is sufficient blood flow .
a previous report showed that extensive non - viable bowel recovered to some extent after withholding resection and waiting for normal function to return .
non - viable intestine may recover with adequate blood flow and may change a fibrous band without lumen with the absence of blood flow .
the preservation of seemingly non - viable intestine , however , represents a great challenge .
ischemic reperfusion injury and necrotic change can induce severe systemic damage that can not always be regulated by intensive care and may even be fatal
. there may be no gold standard for treating extensive necrotic bowel with midgut volvulus .
preservation of involved bowel may offer a possible treatment method for catastrophic midgut volvulus in the case that the extensive areas of apparently non - viable intestine have moderate blood supply .
now , we have no objective scientific criteria for judgment with regard to sufficient blood flow to recover from the necrotic bowel
. we mainly decide whether the necrotic bowel is resected or not , dependent on the macroscopic or pathological appearance of it .
many scientific data on the sufficient blood flow for regeneration of non - viable intestine need be accumulated .
even when intestinal viability is questionable , preservation enables the chance of regeneration if there is macroscopic sufficient blood flow .
schematic images for the operative procedures .   a  the first operative procedure .   b  the second - look operative procedure .   c  the third operative procedure .
the appearance of the bowel is markedly improved compared with that after the first operation , suggesting a sufficient blood supply .
the intestine is paper - thin and distributed in a patchy and circumferential manner ( arrows ) , appearing necrotic and non - viable .
pathological findings of the paper - thin intestine ( h / e stain ) at second laparotomy showing full - thickness necrosis with hemorrhage .
 abstractmidgut volvulus is a highly life - threatening condition that carries a high risk of short gut syndrome . 
 we report a case of catastrophic neonatal midgut volvulus in which second - look laparotomy revealed apparently non - viable remnant small intestine but with a moderate blood supply . 
 full - thickness small intestine necrosis was distributed in a patchy fashion , with non - viable and necrotic areas distributed so widely that no portion of the intestine could be resected . 
 a section of full - thickness necrotic intestine preserved at surgery was able to regenerate , and normal function was restored over a period of 1 month . 
 this case indicated that intestinal resumption may be dependent on blood flow . 
 even when intestinal viability is questionable , preservation enables the chance of regeneration if moderate blood flow is present . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
Conflict of interest