A Case of Reversed Rotation of the Midgut in an Adult

A case of reversed rotation of the midgut in an adult is reported. A 78-year-old man complaining of intermittent abdominal pain and bilious vomiting was admitted to our hospital. He had a similar episode in his adolescence, which improved spontaneously. A barium enema study demonstrated extrinsic obstruction of the transverse colon and a mobile cecum. An upper gastrointestinal tract series with Gastrografin revealed almost complete extrinsic obstruction of the duodenojejunal junction which deviated to the right of the vertebrae. A preoperative diagnosis of suspicion of reversed rotation of the midgut was made. At surgery the reversed rotation of the midgut was identified as of the retroarterial right-sided cecum type, according to the classification by Amir-Jahed, and volvulus was not present. Duodenal obstruction was caused by dense adhesions involving the duodenojejunal junction and mesentery. The adhesions were dissected and the entire intestines were placed in the position of nonrotation by 180° anticlockwise rotation. Ladd's procedure with appendectomy was performed. The patient had an uneventful course for a year after surgery. Reversed rotation is extremely rare, 35 cases having been reported in Japan from 1976 to 1990. Thirteen of the patients were adults. Only 7 of 31 surgical cases were diagnosed as reversed rotation preoperatively. Ladd's operation was the most common procedure in the recently reported cases. Although reversed rotation is a rare congenital anomaly, particularly in adults, its clinical course and the findings of barium enema study and upper gastrointestinal series are distinctive, and a thorough knowledge of embryology and anatomy will help us with preoperative diagnosis and proper treatment of this disorder.