POSTGRAD. MED. J. (I963), 39, 534

DUODENAL ILEUS AND INTESTINALMALROTATION

A Report on Two Cases Occurring in Adults

R. A. ROXBURGH, M.B., BCh.(Cantab.), F.R.C.S., F.R.C.S.E.Lately Surgical Registrar, Central Middlesex Hospital, Park Royal, London, N. W. io

THERE has been a tendency for many years nowto relegate the concept of duodenal ileus in adultsto the limbo of forgotten things. Perhaps onereason why the diagnosis is unfashionable is thatthose who suffer from the condition often belongto that unhappy band of wanderers whose com-plaints of vague dyspepsia remain undiagnosedafter repeated barium meals and cholecystograms.From time to time some of these patients have a'bilious attack' and when, after a few days, theattack subsides spontaneously the doctor may beonly too thankful and feel disinclined to investigatethe patient yet again for fear of making him stillmore 'introspective'.The condition is one of extrinsic duodenal

obstruction and Wilkie thought that it was due tothe superior mesenteric artery being stretchedtightly across the duodenum. This theory has nowbeen largely discredited and replaced by one thatpostulates congenital bands as the obstructingagent; nearly always (89%, Louw, I960) thesebands are associated with an anomalous rotationof the gut, and this in turn is frequently but byno means invariably associated with a volvulus ofthe midgut. Thanks largely to the work of Dott(1923), Ladd (I933) and Ladd and Gross (I94I),padiatric surgeons have for many years recognizedrotational anomalies as a cause of intestinalobstruction, but general surgeons seem to be lessfamiliar with it in adults. Findlay and Humphreys(1956) and Louw (I960) have drawn attention tothe occurrence of the condition in adults.

This paper reports two adult patients withchronic duodenal ileus who were operated on in aphase of acute duodenal obstruction; both of themhad suffered from 'digestive upsets' for manyyears (26 and I4 respectively) and both were curedby placing the bowel in the position of non-rotation.

Unless a surgeon is familiar with the anomaliesof rotation that may occur and their treatment he isliable to be perplexed when suddenly confrontedon the operating table with a case of malrotation.

*Present address: St. James's Hospital, Balham,London, S.W.I 2.

At least this was certainly true in the first casereported below and the measures taken on thatoccasion were impromptu; the second patientalso presented unexpectedly but by that time astudy of the problems posed by the first case ledto the operation being carried out in a moreorthodox manner.

Normal Intestinal RotationFor a full account of the rotation of the gut the

reader is referred to the notable article by Dott(1923) but for the moment Fig. i may help torefresh the memory. The diagrams are intendedto show how, with the aid of a couple of pipecleaners, one may demonstrate the fundamentalsof the mechanism of rotation of the midgut loop.Embryology does not lend itself to facile illustra-tions and the model is not a perfect representationof what happens but it nevertheless serves ourpresent purpose well enough.At the fourth week the enlargement of the intra-

abdominal organs is so great that the gut is forcedout through the umbilical orifice and into theumbilical sac as a physiological umbilical hernia.Rotation occurs partly there and partly as itreturns to the peritoneal cavity.The first point to note is that it is only the

midgut that rotates and this is emphasized in Aand C which show how the ring, middle and indexfingers press the same bit of pipe cleaner on to thesame bit of table-top throughout so that thebeginning of the 'midgut', the beginning of the'superior mesenteric artery' and the end of the'midgut' remain fixed during the manipulations,as indeed they do in the embryo. The pre- andpost-arterial mesenteries have been hatched-in inthe diagrams but they have to be imagined in themodel. 'B' illustrates how the midgut loop rotatesanti-clockwise through three right angles from itsinitial position in the sagittal plane.

'C' illustrates how the duodenum comes to liebehind the superior mesenteric artery and how itacquires a further covering of peritoneum, namelythat of part of the post-arterial mesentery. Nor-

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September I963 ROXBURGH: Duodenal Ileus and Intestinal Malrotation 535

IIJUNUM. I

* l W 1iF : -vf: * l

FIG. i.-See text.

mally most of this post-arterial mesentery gets'plastered down' against the posterior abdominalwall (and fuses with the peritoneum already there)right up to the line of the superior mesentericartery. The pre-arterial mesentery, however, re-mains hanging free as the mesentery of the smallbowel rather like the fly-leaf of a book. The longoblique attachment of the root of the mesenteryacross the posterior abdominal wall is thus ex-plained. Fig. C also illustrates how, at the end ofthe second stage of rotation, the cmcum is sub-hepatic in position. The downward growth of thec'cum and the various fixations already mentionedconstitute the third stage of intestinal rotation.

Abnormal Intestinal RotationA number of faults can occur during the process

of rotation:(i) The gut may never extrude at all; this occurs

in extroversion of the cloaca.(ii) If it does extrude it may fail to return; the

child is then born with an exomphalos.(iii) If it does return it may in so doing fail in

a greater or lesser degree to rotate.(a) Complete failure of rotation results in non-

rotation wherein the duodenum runs straightdown the right paracolic gutter to a smallbowel that lies in the right iliac fossa. Thesmall bowel ends by entering the large bowelfrom the right side. The ascending colonlies more or less in the midline and the

RIGHT HALF O.

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transverse and descending colon are on theleft side of the abdomen. The condition israre.

(b) Partial failure of rotation: sometimes onlythe post-arterial loop rotates but cannot doso completely because the pre-arterial loophas failed to do so; the latter thus blocks thefurther progress of the former. On otheroccasions the pre-arterial loop rotates re-versely in front of the artery but comes to ahalt when it meets the post-arterial loopcoming round in front of the artery from theother side.The third stage of rotation is a misnomer

because by the time it is reached all rotationshould have been accomplished. The thirdstage really consists of various peritonealfusions whereby the bowel is anchored in itsproper position. If rotation has been im-perfect then fixation will be abnormal (i.e.deficient or misplaced) and even when thebowel rotates properly fixation may yet be

El

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POSTGRADUATE MEDICAL JOURNAL

abnormal. When fixation is deficient, vol-vulus is possible, and when it is misplacedobstruction is possible. It is most im-portant to appreciate that both volvulus andobstruction by abnormally placed bandsfrequently occur in the same patient and inevery case both causes must be looked for.The exact details of these errors of rotation

and fixation are very variable and examplesof this type are grouped together under theterm malrotation.

(iv) As the gut returns it may rotate clockwiseinstead of anticlockwise and the discovery of atransverse colon running behind the superiormesenteric vessels and duodenum stigmatize theanomaly as reversed rotation. The condition isvery rare.

Case ReportsCase IOn March 5, I96I, a 29-year-old Cypriot was ad-

mitted to the Central Middlesex Hospital as an emer-gency complaining of colicky upper abdominal painand vomiting of three days duration and of painfulspasms of his hands of some eight hours duration.He had himself noticed visible gastric peristalsis. Thepain was eased by vomiting and also if he lay semi-recumbent on his left side. The vomit contained foodthat he had eaten several days previously. He saidthat he had suffered from attacks of abdominal painand vomiting for as long as he could remember andhad been told by his father that he had had them eversince he was 3 years old. When he was 9 years oldhe was investigated in Cyprus and although the radio-logist reported some abnormality of the bowel his owndoctor discounted this as the cause of his symptomsand, attributing the attacks to subacute appendicitis,removed his appendix. The operation was donethrough a right lower paramedian incision and it tookan unusually long time, doubtless due to the appendixbeing in the left iliac fossa. He derived no benefitfrom the appendicectomy and at the age of Izhe hadhis first attack of gastric tetany. While he was servingin the Royal Air Force he was investigated once againand was told that no abnormality had been discovered,The onset of the attacks was completely unpredictablealthough he usually had them at about monthlyintervals. Between attacks he was perfectly well andmaintained a constant weight. His bowels wereopened regularly and the stools were normal. Hisappetite was good. He had occasional indigestion buthad never had a hiematemesis or melana.On examination he was a thin, wiry young man with

soft sunken eyeballs and a dry furred tongue. Hehad a typical main d'accoucheur and Chvostek's signwas present. His abdomen was soft and scaphoidexcept in the epigastrium where gastric peristalsiscould be observed and whence a succussion splashcould be elicited. No other abnormalities were noted.Serum calcium I0.i mg./ioo ml., sodium 130 mEq./l.,potassium 5.3 mEq./l., chloride 84 mEq./l., and urea84 mg./ioo ml. 20 ml. io% calcium gluconate wereadministered intravenously and the tetany was relievedin about 20 minutes.

Progress. He was admitted to a medical ward witha provisional diagnosis of pyloric stenosis, dehydrationand hypochlorimic alkalosis. Further questioning

FIG. 2a.-Case i: Barium meal at first admission.

FIG. 2b.-Case i: Barium follow-through at firstadmission. Note cmecum just to the left of 5thlumbar vertebra. Barium enema 14 years pre-viously had shown identical picture.

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ROXBURGH: Duodenal Ileus and Intestinal Malrotation

FIG. 3.-Case I: Plain X-ray of abdomen just beforeoperation showing distension of the duodenumand upper jejunum, the distension ending abruptlyin the region of the duodeno-jejunal flexure. Theascending colon is not in the normal position.

revealed that after he had vomited all the food out ofhis stomach he then brought up bile so the diagnosiswas changed to one of subacute high small-bowelobstruction. He improved rapidly on a regime ofgastric aspiration and intravenous saline and a bariummeal and follow-through (Figs. 2a and 2b) carried outfour days after admission was reported on as follows:'Normal appearances of the stomach which emptiednormally. The duodenal cap is normal. Barium wasfollowed through the small and large bowel. Therewas no evidence of obstruction but there was someincomplete rotation of the small bowel which waslargely in the right side of the abdomen and the cecumwas towards the left iliac fossa. Situs inversus partialismesenterium commune'.

Surgical treatment was considered but was decidedagainst for the time being and he was discharged onMarch 15, I96I. In April he had a further attack athome which lasted three to four davs and he hadanother attack in May.He was next seen on October 6, I 96 I, when he

presented himself at the casualty department with a

two-day history of abdominal pain and vomiting. Theclinical findings were identical with those of his earlieradmission. Because he was now known to suffer fromintermittent attacks of high small-bowel obstructionhe was admitted to a surgical ward. X-rays showedincomplete obstruction of the upper jejunum (Fig. 3).Since every previous attack had subsided withoutoperative interference it was hoped that this one wouldprove no exception and it was proposed to study theliterature about situs inversus partialis mesenteriumcommune during the expected remission so that the

correct treatment could be undertaken at leisure.These hopes were not fulfilled as he suddenly beganto produce incre:ising quantities of aspirate andoperation had to ble undertaken as an emergency.

Operation. On opening the abdomen through amidline epigastric incision the stomach, which was notnoticeably dilated, and the transverse colon presented.The middle colic veins were enormouslv varicose,some of them being as much as i cm. in diameter(Fig. 4). Something unusual was clearly present so thesmall bowel, which was of normal calibre and colour,was eviscerated and it then became obvious that acomplete midgut volvulus was present. The volvuluswas in a clockwise direction. Its turns were mattedtogether, but they were peeled apart until the bowelwas free from the duodeno-jejunal flexure to thebeginning of the transverse colon and it was thenpossible to see that it possessed a common unattachedmesentery. This long midgut loop was suspendedfrom the superior mesenteric vascular pedicle. As theturns of the volvulus were being unravelled furthersizeable varicosities of the tributaries of the superiormesenteric vein were encountered and it was observedthat their distribution was patchv.A rudimentary gastro-colic omentum was divided

and a dilated duodenum was seen running behind thesuperior mesenteric vessels towards the root of thetransverse mesocolon which it traversed by way of anarrow aperture with fibrosed and unyielding margins.Lying at a tangent to the duodeno-jejunal flexure therewas a curious calcified rod about 2 mm. x 4 cm. whosenature was quite obscure, but which could be seen onsome of the X-ray plates when looked for afterwards.There was no evidence of a duodenal ulcer.Once the volvulus had been untwisted anxiety was

felt about the possibility of its recurrence, for not onlywas that likely to lead to a recurrence of symptoms butthe superior mesenteric vessels would once more bescrewed up in the very eye of the volvulus and it seemedonly a matter of time before melena resulted from theintestinal varices or, even worse, a more severe obstruc-tion of the vessels resulted in infarction of the gut.Furthermore, it did not seem wise to leave the duodeno-jejunal flexure sharply angulated in a rigid tunnel. Itwas apparent that these difficulties could most readilybe overcome by reflecting the hepatic flexure over tothe left as it was felt that the resulting widening of theduodeno-colic isthmus would offer the best chance ofpreventing a recurrence of the volvulus and such a stepwould also enable the duodeno-jejunal flexure to befreed from its rigid surroundings. But after a fewtentative snips had been made in the adhesions thatran across the duodenum from the under surface of theliver to the hepatic flexure the manceuvre had to beabandoned because trying to find a plane in densefibrous tissue that contained large varices soon provedaltogether too hazardous an undertaking. Had itbeenpossible to accomplish it the bowel would haveendedup in the position of non-rotation (Ladd II operation)The only solution appeared to be to mobilize the

duodeno-jejunal flexure as it lay within the rigid tunnelin the root of the transverse mesocolon, transect itthere and bring the ends round to the right of thehepatic flexure and anastomose them as they lay in theright paracolic gutter. This was done without diffi-culty and the duodenum then ran straight down theright paracolic gutter to the rest of the small bowelwhich lay entirely in the right iliac fossa, whilst thelarge bowel lay mostly in the left side of the abdomen,i.e. a state of non-rotation had been artificially pro-duced. The most important consequence of this wasthat the duodenum could be seen to be completely free

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538 POSTGRADUATE MEDICAL JOURNAL September I963

i

* .a'

FIG. 4.-Case I: Intestinal varices.

of all possible sources of extrinsic obstruction. Noattempt was made to fix any portion of the bowel andthe abdomen was closed.The patient made a smooth recovery and was dis-

charged on the i ith post-operative day. Bariumstudies carried out four months after operation (Figs.Sa and 5b) showed: 'Normal position and appearancesof the stomach and duodenal cap. Barium passedfreely from the first part of the duodenum downwardsand laterally into the jejunum which was shown lyingentirely in the right iliac fossa. There was no evidenceof obstruction at the site of the anastomosis. Thebarium was followed through and was shown enteringthe cxcum after three hours. The coecum lay in theleft iliac fossa. The ascending colon lay obliquely inthe abdomen and the hepatic flexure was almost in thenormal position'.At the time of writing (one year after operation) he

has been free of all symptoms and has gained a stone(6.3 kg.) in weight.

Case 2At the age of 59 Mrs. E. M. had complained of

abdominal pain, flatulence and vomiting. A bariummeal was carried out and she was told that she had hadan ulcer but that it was no longer present. Symptomscontinued for I4 years until, on May 8, I962, she wasseized with a severe central abdominal pain that con-tinued without remission until she was admitted tohospital the following afternoon. She vomited pro-fusely from the moment the pain began. Four yearspreviously she had had a left ovarian cystectomy for acystadeno-carcinoma.

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FIG. 5a.-Case I: Barium meal four months afteroperation showing duodenum running straightdown right paracolic gutter.

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FIG. 5b.-Case Ii: Follow-through showing cEecum inleft iliac fossa and ascending colon runningobliquely across the abdomen.

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Examination showed a frail old woman who wasdehydrated, cyanosed, and somewhat collapsed. Hertemperature was normal, her tongue dry and furred,and her abdomen slightly distended and tender, thetenderness being maximal in the right iliac fossa.Bowel sounds were sometimes normal and sometimeshigh-pitched. X-rays showed some distension of thesmall bowel but no free gas under the diaphragm.

Subacute high small-bowel obstruction was a possiblediagnosis but one of 'senile appendicitis' was consideredmore probable despite her normal temperature andprofuse vomiting.

Operation. After a preliminary period of resuscita-tion a McBurney incision was made. The peritonealcavity contained a good deal of turbid green fluid. Itwas found that the appendix had been removed at herprevious operation. The McBurney incision wasclosed and a right upper paramedian incision made.There was no evidence of peptic ulceration but theduodenum was seen to be dilated to about twice itsnormal size. To explore the abdomen properly it wasnecessary to divide the adhesions that bound the smallbowel to the ovarian cystectomy scar, but in doing sothe bowel was opened in two places. Repair of theholes was unsatisfactory and a foot of small bowel hadto be resected. Once this had been done it was possibleto eviscerate the whole of the small bowel and it wasthen immediately obvious that a small bowel volvuluswas present. It was reduced by rotating it I8o degreesin an anti-clockwise direction. The viability of thesmall bowel was unimpaired and there was no con-gestion of the mesenteric veins. The small bowel wasgenerally, but very moderately, distended. Furtherexploration revealed that the cmcum and ascendingcolon (neither of which had taken part in the volvulus)had a mesentery and were fairly freely mobile. Itwas not a communal mesentery as that of the smallbowel had an attachment but this was over rather ashorter distance than usual. There was no recurrenceof her ovarian carcinoma.Her history, the presence of a volvulus, the dilated

duodenum and the evident congenital abnormality ofthe attachment of the mesentery seemed sufficientjustification for attempting an extended Ladd operation(Ladd III; Louw, I960) for it was clear that it wasnbt the adhesions resulting from her ovarian cystectomythat were responsible for the obstruction since the onlyreally distended part of the small bowel was from thepylorus to the duodeno-jejunal flexure. Accordingly,the mesenteric attachment was divided off the posteriorabdominal wall right up to the duodenum and thesmall bowel rotated en masse in a clockwise direction sothat it lay in the position of non-rotation with theduodenum running straight down the right paracolicgutter to the rest of the small bowel that lay mostly inthe right iliac fossa. The ascending colon and cacumlay more or less in the midline with the terminal ileumentering the cecum from the right.

Apart from some paralytic ileus she made an un-eventful recovery from the operation and was dis-charged after 22 days. When seen after her returnfrom convalescence she said that she was glad to be ridof the abdominal pain and vomiting that had plaguedher for so long although she still suffered from a gooddeal of wind. She had put on ii lb. (5 kg.) in weight.A barium meal and follow-through showed no evidenceof obstruction and that the position in which the bowelhad been placed at operation had been maintained.

DiscussionEven those who are born with a major anomaly

of intestinal rotation are not necessarily doomedto an untimely death. All of them, however, areunder the constant threat of intestinal obstructionor volvulus, but fortunately in more than half ofthem the threat never materialises.At least a third of those in whom it does have

serious consequences are neonates. In others thecondition characteristically causes repeated attacksof subacute duodenal obstruction from infancyonwards (Case i). In yet others again symptomsappear unheralded and at any age, the oldest suchpatient being that recorded by Kimel andHarrower (I957) who was 79 when operated onfor a midgut volvulus. In this third group thesymptoms may be episodic as in the second groupbut they may consist instead simply of complaintsof chronic flatulent dyspepsia. Finally mentionmay be made of what must be a very small groupindeed, namely those in whom obstruction of theduodenum is only brought about when the patientwith abnormal peritoneal attachments is placed ina plaster jacket in hyperextension. The bands mayonly then be made taut enough to compress theduodenum.The first patient had had a complete midgut

volvulus with intermittent attacks of duodenalileus since his earliest years, and until his penul-timate attack his symptoms had defied diagnosis.Gardner and Hart (I934) in an analysis of 88 casesof volvulus of the entire mesentery collected fromthe world literature found only 17 patients in theage-group 3 to 27 years. But there is probably anincreasing awareness of the condition nowadaysfor Louw (I960) was able to report 54 cases ofduodenal ileus seen over a period of only fiveyears and no less than I9 of them were adults ofwhom nine had either an acute or chronic volvulus.The cause of the attacks of intestinal obstruc-

tion in Case i was probably an intermittentworsening of the volvulus which, by 'taking upthe slack' in the uppermost jejunum, caused asharpening of the angulation at the rigidly fixedduodeno-jejunal flexure, and it is likely that con-stant slight tightening and loosening of thevolvulus over many years was the cause of thescarring and contraction at the root of the commonmesentery. In Louw's (I960) series there were32 cases of chronic duodenal ileus and in the iIwho had an associated chronic midgut volvulusthis fibrosis was present.The rotation of the gut in the first patient had

stopped part of the way through the third stageof rotation; that is to say, caecal descent hadoccurred but adhesion of the mesentery of theright colon to the parietal peritoneum on theposterior abdominal wall had not taken placeexcept over a very short distance at the hepaticflexure. When such a complete failure of fusion

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occurs the mesenteries of the small bowel andof the right colon are confluent (mesenteriumcommune) and the midgut dangles from thesuperior mesenteric vascular pedicle without anyother support or attachment. This is a positiveinvitation to volvulus and although a high pro-portion of patients with rotational anomalies who:get intestinal obstruction have a volvulus (48%,Louw, I960) it must not be thought that volvulusis a sine qua non of obstruction for many of thesecases, both those with volvulus and those without,have adventitious peritoneal bands and adhesionsthat can cause intestinal obstruction (generallyduodenal), and it was a realization of this factthat enabled Ladd (I933) and Ladd and Gross(1941) to revolutionize the surgery of the neonatalobstructions due to these developmental errors.The corollary is that if a volvulus is present amere untwisting of it is unlikely to prove anadequate operation. What must be done is todemonstrate that the duodenum is free of allextrinsic obstructions. At least this may simplymean dividing congenital batids that obstruct theduodenum as they run laterally across it froman undescended subpyloric cecum (Ladd, 1933).At most it may be necessary to mobilize the rightcolon (as for a right hemicolectomy) and, if theroot of the mesentery has achieved an attachment,to continue this mobilization over to the left*behind the superior mesenteric vessels and thenup over the front of the duodenum. In this waythe duodenum carm be seen in its entirety. Ifthe bowel is then rotated in a clockwise directionthe duodenum can be straightened out and madeto lie in the right paracolic gutter in the positionof non-rotation, whilst the colon lies towards theleft side of the abdomen (Ladd IV; Louw, I960).By such a manceuvre the duodenum is free fromall constricting agents and the duodeno-colicisthmus is made as wide as possible so that arecurrence of the volvulus is rendered less likely.The operation that was carried out in Case iresulted in complete freeing of the duodenum,but the duodeno-colic isthmus was not materiallywidened so that recurrence of the volvulus isperhaps a little more likely than if a Ladd II(Ladd and Gross, 194I) had been performed,though less probable than if the volvulus hadbeen merely untwisted. A Ladd II operationwas in fact attempted but the size of the varicesand the difficulty of being sure of avoiding themin the dense scar tissue soon proved too greatand the attempt was abandoned in favour ofend-to-end duodeno-jejunostomy. The latteroperation would be highly undesirable in aninfant as -it would involve the transection andanastomosis of bowel and one of the great advan-tages of the Ladd operation is that bowel is not

opened. Other advantages are that even in itsmost extended form (Ladd IV, Louw, I960) itcan be carried out very rapidly and with virtuallyno blood loss. All these factors are of greatimportance when it is remembered that many ofthe patients who need the operation are neonateswho are already seriously ill from intestinalobstruction.The formidable intestinal varices were prob-

ably due to the superior mesenteric vein beingsubjected to more or less continuous partialobstruction. Such varices have been reportedonly on a few occasions (Aldridge, I96I; Findlayand Humphreys, 1956 (Case i3); Gardner andHart, 1934; Lee and Nye, I932) and only onone occasion have they caused melkna (McIntoshand Donovan, 1939 (Case 20)), but neverthelessthe fears felt at operation about the risk of bleed-ing or thrombosis seem justified on common-sense grounds. The patchy distribution of thevarices has already been mentioned and at thetime there seemed no obvious explanation forthis, but it is possible that it was due to some ofthe radicles of the superior mesenteric vein beingsupported externally by virtue of being wrappedup in the volvulus, whilst others, not so wellsupported, were obliged to dilate in the face ofincreased venous pressure.The rotation of the gut in the second patient

had proceeded a little further than it had in thefirst, but the attachment of the mesentery wasimperfect as evinced by the fact that it was overa shorter distance than usual and that the rightcolon had a mesentery. Some weeks after theoperation she volunteered that it had beennecessary to take her back to theatre a few daysafter her ovarian cystectomy because 'somethinghad twisted'. Enquiries were made at the hospitalconcerned but unfortunately the operation noteswere missing, but it was clear from the notesthat remained that her abdomen was reopened onaccount of intestinal obstruction and it is tempt-ing to deduce from that and from her use of theword 'twisted' that she had had a small bowelvolvulus on that occasion too and that it hadbeen treated by simple untwisting. If thisdeduction is correct then it would seem that herintestines were predisposed to volvulus.

If malrotation of the bowel is diagnosed as anincidental finding no treatment is required butonce the condition has caused symptoms it isunwise to treat the patient conservatively, for ofGardner and Hart's I7 patients with chronicduodenal ileus no less than eight died duringacute exacerbations of the attacks from which theyhad suffered intermittently throughout their lives.Furthermore, as Louw (I960) points out, theduodenum sags increasingly downwards as one

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gets older, whilst the duodeno-jejunal flexureremains more constant in position, so that theangle at the flexure becomes progressively moreacute; thus once symptoms have occurred theexpectation must be that they will get worse astime goes by. It is now widely agreed that theideal operation is one of the Ladd type and thatsuch an operation is greatly to be preferred to aside-to-side duodeno-jejunostomy. Louw (I960)has treated 30 cases of chronic duodenal ileus (i8children and I2 adults) by the Ladd operation oran extension of it and the results have beenexcellent. None of his patients has died.A large number of operations have been

described in the past for this condition but theoperation carried out in Case i does not seem tohave been used before; it was improvized to dealwith an unfamiliar situation but it appears to havebeen a success and might perhaps again be of useif massive varices and dense scarring prevent theorthodox and highly satisfactory Ladd procedurefrom being carried out.Those whose intestines are naturally in the

position of non-rotation are liable to mid-gutvolvulus and yet it is advocated that patients whorun into trouble from an incompletely rotatedbowel should have their intestines deliberatelyplaced in a position of non-rotation. The explana-tion of the apparent paradox is that it is only byde-rotating the bowel that one can be certain thatno bands occlude the duodenum; the risk offurther trouble from undetected bands compress-ing an incompletely explored duodenum appearsto be greater than the risk of a volvulus developingin an artificially de-rotated bowel. This is partlybecause bands and adhesions are so commonly thecause of the patient's symptoms, partly becausewidening of the duodeno-colic isthmus that re-sults from de-rotation reduces the likelihood ofvolvulus, and partly no doubt because the rawareas left in the more extended operations of the

Ladd type result in the bowel being anchored bypost-operative adhesions.

If the rare condition of reversed rotation shouldcause obstruction of the right colon then thiscomplication should be treated by cwcostomy (toanchor the cxcum as well as to relieve the obstruc-tion) and this should be followed by a transverse-sigmoid anastomosis for the condition is notamenable to a sleight-of-hand anatomical correc-tion along the lines of an extended Ladd operation.Each case must be dealt with on its merits and

certainly de-rotation of the bowel is not a universalpanacea for all rotational anomalies but it isfrequently applicable and it is essential to bear theprocedure in mind when considering how best todisentangle an unfamiliar disposition of the bowels,for the exact cause of the intestinal obstruction isseldom apparent until the abdomen has beenopened and it is then too late to ponder theproblem in a library.

Summaryi. The normal mechanism of the rotation of the

bowel and the derangements thereof are outlined.2. Two adult cases of duodenal ileus associated

with malrotation and volvulus are described.3. The first case was treated in an unorthodox

way (end-to-end duodeno-jejunostomy) partly onaccount of ignorance of how such a case should betreated and partly because massive intestinalvarices prevented the performance of what wouldhave been an orthodox operation. The secondcase, which presented seven months after the first,was treated by an extended Ladd operation. Inboth the result has been satisfactory.

I am indebted to Mr. J. W. P. Gummer for per-mission to report these cases and for his helpfulcriticism, to Mrs. I. M. Prentice for the drawings, toDr. Frank Pygott for the X-ray reports, and to MissYvonne Scott for secretarial assistance.

REFERENCESALDRIDGE, R. T. (I96I): Intestinal Malrotation in the Adult, N.Z. med. J., 60, 420.DOTT, N. M. (1923): Anomalies of Intestinal Rotation: Their Embryology and Surgical Aspects with a Report of

Five Cases, Brit. J. Surg., II, 251.FINDLAY, C. W., and HUMPHREYS, G. H. (1956): Congenital Anomalies of Intestinal Rotation in the Adult, Int. Abstr.

Surg., 103, 417-GARDNER, C. E., and HART, D. (1934): Anomalies of Intestinal Rotation as a Cause of Intestinal Obstruction, Arch.

Surg., 29, 942.KIMEL, V. M., and HARROWER, H. W. (1957): Obstruction of the Duodenum and Cecum, Malrotation of the Bowel

and Midgut Volvulus in an Adult Patient with a Gastroenterostomy, New Engl. J. Med., 257, I 58.LADD, W. E. (1933): Congenital Obstruction of the Small Intestine, J7. Amer. med. Ass., 101, 1453.

and GROSS, R. E. (1941): 'Abdominal Surgery of Infancy and Childhood'. Philadelphia: W. B. Saunders.LEE, A. E., and NYE, L. J. J. (19.32): Chronic Duodenal Obstruction Due to Non-rotation of the Midgut Loop, with

Superadded Volvulus, Med. Y. Aust., 2, i8.Louw, J. H. (I960): Intestinal Malrotation and Duodenal Ileus, J. roy. Coll. Surg. Edinb., 5, Ioi.MCINTOSH, R., and DONOVAN, E. J. (1939): Disturbances of Rotation of the Intestinal Tract: Clinical Picture Based

on Observations in Twenty Cases, Amer. Y. Dis. Child., 57, iI6.

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