D. M. Schwartz1, Z. V. Fong1, D. C. Chang1 1Massachusetts General Hospital,General Surgery,Boston, MA, USA
Introduction:
Small bowel volvulus in children is a devastating condition that most commonly occurs in patients with congenital malrotation. Failure of normal rotation and fixation of the intestine leads to a narrowed mesenteric root, which predisposes these patients to midgut torsion. The resultant bowel ischemia and obstruction require expedited surgical management to avoid the serious consequences of short gut syndrome, sepsis and death. Small bowel volvulus predominately affects the pediatric population with up to 80% of patients affected within the first month of life and 90% within the first year. Current clinical knowledge of this disease is based mainly on analyses of single institution experiences or case studies. Using a national database inquiry, we aim to characterize the epidemiology and outcomes of this disease at the population-level and to define predictors of mortality.
Methods:
The Nationwide Inpatient Sample database, was retrospectively reviewed for patients 18 years old or less with small bowel volvulus (International Classification of Diseases, 9th Edition [ICD-9] code 560.2 excluding gastric/colonic procedures) from 1998 to 2010. Bivariate analysis was performed to define the demography of patients with small bowel volvulus. Baseline characteristics of patients who required small bowel resection were compared using bivariate statistical tests (Fisher Exact and Student’s T-tests). Predictors of mortality were modeled using logistic regression.
Results:
There were 2422 hospitalizations for small bowel volvulus, and of these, 1751 (72.3%) required surgical intervention. Small bowel volvulus occurred more frequently in male (61.3%) than female (38.7%, ratio 1.6 to 1) patients. Most cases presented emergently (86.1%), and the majority of patients were treated at urban (91.3%) and teaching hospitals (72.3%). The overall mortality rate was 3.1%. Mean age was 7.2 years (SD 6.4 years), and this average was unchanged when the cohort was restricted to only those patients with volvulus as their primary diagnosis. Patients who required small bowel resection were more likely to present with shock (50% vs. 19.5%, p<.0001) or peritonitis (46.9% vs. 19.6%, p< .0001), and more likely to be premature (20.3% vs. 33.3%, p<.014). On multivariate regression, predictors of mortality identified included vascular insufficiency (incidence 18.5%, OR 30.5, 95% C.I. 10.3 – 90.1, p<0.001) and shock (incidence 3.7%, OR 8.8, 95% C.I. 2.6 -29.3, p<0.001).
Conclusion:
This epidemiological study demonstrates an analysis of the trends of small bowel volvulus in a pediatric populace that accurately represents the national population. Male predominance of this disease is confirmed and a real world mortality rate of 3.1% is defined. Mean age for this cohort is higher than has been described previously. Vascular insufficiency and shock were strong predictors of mortality, and should be incorporated in future clinical nomograms and risk-calculators.