Recurrent duodenal obstruction caused by Ladd’s bands in an adult: a case report and review of the literature

Abstract

Introduction:

Intestinal malrotation is a congenital anomaly resulting from incomplete midgut rotation. While it most commonly becomes symptomatic in infancy, adult presentations are rare and pose diagnostic difficulties. In particular, obstruction due to persistent Ladd’s bands in adults is uncommon and requires surgical attention.

Presentation of the case:

We describe a 43-year-old male patient with recurrent episodes of small-bowel obstruction over 3 years. The initial presentation included bilious vomiting and CT evidence of duodenal obstruction, which was managed conservatively. Upon recurrence, diagnostic laparoscopy identified only adhesions; however, repeated imaging and persistent symptoms prompted a second laparoscopic intervention. Intraoperatively, intestinal malrotation with rigid Ladd’s bands compressing the duodenum was identified. A laparoscopic Ladd’s procedure was performed, including division of the bands and repositioning of the bowel. An appendectomy had been performed in childhood. The patient recovered uneventfully and remains symptom-free at follow-up.

Discussion:

Adult intestinal malrotation may present with nonspecific symptoms such as intermittent abdominal pain, nausea, or obstruction. Characteristic CT findings (e.g., inverted mesenteric vessels and abnormal bowel positioning) should raise suspicion for malrotation. Although guidelines for adults are lacking, the Ladd’s procedure remains the standard of care. An elective approach may reduce complication rates compared with emergency surgery.

Conclusion:

In adults with recurrent duodenal obstruction and suggestive imaging findings, malrotation with Ladd’s bands should be considered. Early surgical intervention via a Ladd’s procedure can relieve symptoms and prevent serious complications.

Introduction

Asymptomatic intestinal malrotations are comparatively frequent in childhood, with an estimated prevalence of 1 in 200–500 live births. In contrast, symptomatic malrotation is rarer, occurring in approximately 1 in 6000 live births[1]. Most cases become symptomatic during the first 4 weeks as a newborn[2].

HIGHLIGHTS

• Ladd's bands can be a rare cause of duodenal obstruction in adults.

• The treatment of choice is Ladd's procedure in adults as well.

• A laparoscopic approach seems to be the preferred option.

During fetal development, the intestine undergoes a physiological 270° counterclockwise rotation, alongside fetal ligaments known as Ladd's bands, ultimately positioning the cecum in the right lower abdomen, with a fusion plane between the mesocolic and parietal peritoneal fascia. Malrotation refers to an improper or incomplete rotation of the intestine around the mesenteric axis, with the cecum remaining in an atypical location and the duodenojejunal junction anterior to the superior mesenteric artery (SMA) instead of in a posterior location. Subsequently, Ladd's bands remain as strong ligaments to the retroperitoneum at different segments of the intestine, which may lead to intestinal obstruction or volvulus due to intermittent torsion of bowel loops[3].

Since malrotation typically becomes symptomatic and is treated during childhood, its incidence in adults is rare, reported at approximately 0.2%[4]. In adults, malrotation is usually asymptomatic and is often an incidental radiologic finding[5]. The diagnostic modality of choice is a CT scan, which has a diagnostic accuracy of 80%[3].

Here, we report a case of recurrent duodenal obstruction due to Ladd’s bands and provide a comprehensive review of the current literature on this rare entity to illustrate the difficulties in diagnosing and treating it.

This case report has been prepared in accordance with the SCARE checklist.

Presentation of the case

This case report describes a 43-year-old male patient with recurrent abdominal pain. Symptoms started in 2020. The medical history revealed intermittent pain and nausea, which would usually resolve spontaneously. An appendectomy had been performed in childhood. No other comorbid conditions were present. In 2020, he presented to the emergency department with symptoms of ileus, including bilious vomiting, which improved after placement of a nasogastric tube. CT imaging revealed a mechanical ileus in the pars horizontalis duodeni (Fig. 1A). Gastroscopy showed a stenosis 70 cm from the upper dental arch (Fig. 2). We preferred a conservative approach by stimulating bowel peristalsis. The symptoms resolved with conservative treatment, and no further examinations or treatments were performed.

Figure 1.

Representative images from contrast-enhanced CT scans at the respective admissions. The arrow points to the location of the ligaments and subsequent cause of ileus. (A) Image taken in 2020; (B) image taken in 2021; (C) image from the final admission in 2023.

Figure 2.

Image from a gastroscopy showing a stenosis 70 cm from the upper dental arch.

In 2021, he was readmitted with recurrent symptoms of ileus. He presented with a similar CT scan and symptoms compared with his previous hospital stay (Fig. 1B). Therefore, we restarted conservative therapy, which did not significantly improve the symptoms. However, as the CT scan showed a torsion of the duodenum, we decided to perform a diagnostic laparoscopy. Intraoperatively, we identified and released an adhesion related to the previous appendectomy that was thought to be the cause of the obstruction. Afterward, the small bowel showed good motility without any signs of stenosis. Additionally, we noted a hypermobile ascending colon. Following the procedure, the patient showed clinical improvement and was discharged.

In 2023, the patient presented again with an ileus. CT scans showed a similar configuration, with obstruction of the descending duodenum, as in previous admissions (Fig. 1C). In retrospect, he reported frequent postprandial bloating for several years, which improved after lying down for a few hours. Once again, laparoscopy was indicated. Given the repeatedly similar CT scans, we assumed that intestinal malrotation was responsible for the duodenal obstruction. We performed a laparoscopic Ladd’s procedure, placing the patient in the supine position and using a trocar placement in the left lower quadrant, as we would for a right colectomy. Intraoperatively, we saw the cecum in the upper right abdomen and a bloated duodenum. After repositioning the intestine, with the ascending colon to the patient’s left and the small intestine to the right, we identified Ladd’s bands (Fig. 3A, B) and released them completely. These ligaments were much more rigid than typical adhesions and exhibited multiple layers that had to be dissected before the duodenum could be released completely. This resulted in sufficient decompression of the duodenum and a rapid, uneventful recovery (Supplemental Digital Content Figure 1A, B, available at: https://links.lww.com/MS9/B319). The surgical procedure resembles an oncologic right colectomy, in which the fascia duodeno-pancreatica is dissected to fully mobilize the right colon.

Figure 3.

(A, B) Intraoperative images showing a dilated duodenum caused by Ladd's ligaments. Blue circle: dilated duodenum; blue arrows: Ladd's ligaments; white arrow: first jejunal loop; white circle: cecum; black circle: terminal ileum. Figure 3A focuses on the ligaments. Figure 3B focuses on the correct placement of the intestine before dissecting the ligaments.

Postoperatively, follow-up examinations showed normal bowel passage without any signs of stenosis or delayed motility (Supplemental Digital Content Figure 2, available at: https://links.lww.com/MS9/B319), and the patient has remained symptom-free to date.

Discussion

This case highlights that Ladd’s bands, though rare, can cause recurrent small bowel ileus in adults. Diagnosis is challenging due to variable symptoms, which depend on the height of the bands[6]. Reported cases describe a wide range of symptoms, from acute abdominal pain with bilious vomiting to chronic, recurrent abdominal discomfort or incidental findings on imaging performed for unrelated reasons (Table 1).

Table 1.

Review of literature.

Authors & year	Location of stenosis	n		Age (years)	Gender	Symptoms	Duration of symptoms	Previous surgery	Diagnostic	Image	Approach	Additional information
Wagh A, 2024[7]	Duodenal	1	14		female	Pain, vomiting	3d	No	Ultrasound, CT	Reverse superior mesenterical vessels	Laparotomy
Nichat P, 2024[8]	Duodenal	1	16		male	Colicky pain, acute onset, multiple bilious vomiting	n.a.	No	X-ray, ultrasound, CT	Malrotation, twirling of mesentery along with SMA&SMV, twisting of the transverse colon below duodenojejunal segment	Laparoscopy, conversion due to technical challenges
Naddouri J, 2024[5]	Small bowl	1	18		female	Abdominal distension, flatus, incapacitiy to defecate	3d	No	CT	Dilatation of small bowel, whirl sign	Laparotomy
Wagh A, 2024[7]	Duodenal	1	19		male	Pain, vomiting	4d	No	CT	Whirlpool of SMA&SMV	Conservative
Yin Y, 2017[9]	N.a.	1	23		female	Pain, vomiting	n.a.	n.a.	MRI	Intestinal obstruction	Laparotomy	Pregnancy with twins
Wagh A, 2024[7]	Duodenal	1	26		male	Pain	3d	No	X-ray	Air-fluid levels	Laparotomy	Stoma
Haghiri M, 2022[10]	Duodenal	1	26		female	Bilious vomiting, 25.SSW, weakness, weight loss, Z.n. HELLP2x	4y	No	Endoscopy, MRI	Dilatationof stomach an duodenum	Laparotomy	2 pregnancies in advance
Wagh A, 2024[7]	Midgut	1	36		female	Pain, vomiting	1,5y	No	Ultrasound, CT	Cholelithiasis adenomyomatosis, chronic cholezystitis, midgut malrotation	Conservative	Only CCE
Islam S, 2024[11]	Duodenal	1	43		male	Pain, nausea, vomiting, diarrhea, distension, weight loss	5d	No	X-ray, CT	Whirlpool of SMA&SMV	Laparotomy
Park YJ, 2015[12]	Duodenal	1	44		male	Nausea, vomiting, diarrhea	5d	No	Endoscopy, X-ray, CT	Dilatation duodenum, whirlpool	Laparoscopy, conversion due to technical challenges
Grassi C, 2020[4]	Ileum	1	44		female	Pain	n.a.	n.a.	X-ray, CT	Air-fluid level, conglomerate ileal loop, thickened walls	Laparoscopy, conversion due to adhesions
Yin MD, 2024[13]	Small bowl	1	45		female	Nausea, bilious vomiting, weight loss	Since childhood	No	Endoscopy, CT	Whirpool, Ileus, dilatation	Laparoscopy, conversion due to technical challenges
Lieu DQ, 2023[3]	Duodenal	1	47		Female	Abdominal pain, vomiting	n.a.	n.a.	Endoscopy, cMRI, CT	Dilatation of D1-2-3, malrotation	Laparoscopy
Arabi NA, 2020[14]	Duodenal	1	52		Male	Painless jaundice	2 m	No	Ultrasound, CT, MRI	Distal cholangiocarcinoma, inversion of superior mesenteric vessels, malrotation of bowel	Laparotomy	CCA
Fung AT, 2017[15]	Small bowl	1	53		Male	Pain postprandially, nausea, vomiting, obstipation, distension	4 h	No	CT	Malrotation small bowel, small bowel ischemia	Laparotomy
Jabra SB, 2023[16]	Small bowl	1	54		Male	Pain, vomiting	1d	No	CT	Mechanical obstruction	Laparotomy
Melkonian V, 2020[17]	Small bowl	1	56		Male	Child C cirrhosis (MELD 22), incidentally, nausea, vomiting, pain	2d	Umbilical hernia repair	CT	Malrotation, whirlpool	Laparotomy
Torre A, 2022[18]	Colon	1	62		Female	Pain, obstipation	5d	No	X-ray, CT	Whirlpool	Endoscopic detorsion, laparotomy
Børgager M, 2021[6]	Small bowl	1	68		Male	Pain, flatus, nausea	14d	No	CT	Malrotation	Laparoscopy
Schwab ME, 2022[19]	Duodenal	1	84		Male	Diffuse abdominal pain, persistent emesis	3d	No	CT	Malrotation, duodenal pneumoatosis intestinalis, abnormal relationship between SMA and SMV, location auf the third portion auf the duodenum, atypical location of the proximal small bowl	Laparotomy
Kassem MW, 2018[2]	Duodenal	1	87		Female	Postmortem (heart failure)	n.a.	No	n.a.	n.a.	n.a.	Post mortem examination, incidental
Zheng ZH, 2014[20]	Midgut	8	41,25 (mean; 14-63)		5 male, 3 female	Distension, anorexia, fatigue, nausea, vomiting, pain	n.a.	No	CT, ultrasound, MRI (pregnant)	Malrotation, whirlpool volvulus of SMA&SMV	n.a.

The most common symptom in adults is nonspecific abdominal pain[12]. It can be assumed that some patients are mistreated, which can even lead to the attribution of a psychiatric disorder [12].

While patients with mild symptoms could be handled conservatively in the absence of acute complaints[7], others had severe symptoms requiring urgent surgery.

Our review of the literature shows an almost equal gender distribution (44.8% female; 55.1% male), and the mean age at diagnosis is 43.7 years (range: 14-87 years). 50% of cases showed duodenal stenosis, 40.9% were localized to the small bowel, and one case (4.5%) involved the colon. Acute symptoms typically lasted several days (1–5 days), though some patients had recurrent episodes since childhood. Due to the nonspecific nature of the symptoms, many cases are likely to be underdiagnosed or diagnosed after many years. At 77.2%, abdominal pain is the most common symptom, followed by vomiting (68.1%). Nausea (31.8%) and abdominal distension (18.1%) are also described in these case reports. Weight loss (13.6%), constipation (13.6%), diarrhea (9.1%), and fatigue (9.1%) are less frequently mentioned in the literature.

Most patients had no prior surgical procedures (81.8%).

Given the broad symptom variability, radiological evaluation is crucial, bearing in mind signs of malrotation[10], and has been the most frequently used diagnostic modality reported in the literature (81.8%). Key findings include an inverted mesenteric axis, i.e., with the SMA being on the right and the superior mesenteric vein (SMV) being on the left side^[8,18^]. Moreover, additional findings include a duodenum that fails to cross the midline, intestinal twisting, and/or a cecum in an unusual intra-abdominal position^[14,18^]. A review of the literature showed that most case reports described twirling of the mesenteric vessels (68.1%). In cases of recurrent symptoms with consistent CT findings, as in our case, the possibility of Ladd's bands should be considered.

When imaging remains inconclusive, intraoperative recognition of abnormal anatomy is essential. Typical findings include a left-sided ascending colon and a right-sided small bowel[4]. However, following one’s habits, placing the ascending colon to the right would mask the malrotation. A hypermobile cecum or an unusual position of the appendix may also raise suspicion for malrotation. In such cases, consulting a pediatric surgeon may be advisable, as Ladd’s bands are primarily encountered in children and there are currently no established guidelines for adult treatment due to the low number of reported cases[19].

The treatment of choice is a Ladd's procedure, commonly performed in children diagnosed with intestinal malrotation. A Ladd's procedure includes several steps: First, the surgeon has to reposition the intestine and untwist the volvulus by clockwise rotation. Second, mobilization of the cecum and the duodenum by separating Ladd's bands is crucial (Fig. 3B). Furthermore, it is important to widen the root of the small bowel mesentery by removing adhesions around the SMA[21]. The last step of a Ladd’s procedure includes an appendectomy to avoid future confusion regarding the unusual position of the appendix. Finally, the large bowel is placed in the left colic gutter, while the small intestine can be positioned in the right hemiabdomen. The same procedure is performed in children as well as in adults if congenital malrotation is found[2].

In our case, the patient presented with relatively typical symptoms, including abdominal pain, nausea, and vomiting, with recurrent episodes over the past several years, which ultimately led to a delayed diagnosis of intestinal malrotation. The age at diagnosis, 43 years, corresponds to the typical age reported in the literature, which also notes a slight male predominance of approximately 55%. Furthermore, the fact that prior surgical adhesiolysis had been performed for symptoms of bowel obstruction represents a clinical course that is also commonly described in the literature.

As the stenosis was located in the duodenal region, our patient fits the typical presentation of intestinal malrotation in adulthood. Abdominal CT imaging was performed in accordance with current recommendations and confirmed duodenal stenosis with associated features of bowel obstruction.

Because of previously unsuccessful conservative treatment, which ultimately resulted in recurrent symptoms, we opted for surgical management using a laparoscopic approach. Based on the imaging findings and the patient’s clinical history, we strongly suspected intestinal malrotation preoperatively. Therefore, pediatric surgeons were involved early on, as they possess the greatest expertise in this field. Following intraoperative confirmation of the diagnosis, a laparoscopic Ladd’s procedure was successfully performed. Despite the altered anatomical conditions, the procedure was feasible laparoscopically, as prior diagnostic knowledge significantly facilitated intra-abdominal orientation. As the patient had already undergone an appendectomy during childhood, this was not part of the present procedure.

The indication for surgery versus conservative management remains under discussion[17]. The literature mostly describes pediatric patients, in whom surgery is performed immediately if an acute volvulus is diagnosed, and an elective Ladd’s procedure is performed in patients with chronic symptoms[15]. In most cases (81.8%), surgery was performed; only 9.1% could be managed conservatively. The management of the remaining 9.1% was not clearly described. Conservative management can be an option in some cases[9]; however, recurrence is possible, and failed conservative therapy can ultimately lead to an operation. Therefore, the authors prefer to perform a Ladd’s procedure in adults because predictive factors for developing a volvulus are still unknown^[12,15^]. Melkonian et al reported a higher rate of complications (66%) when a Ladd’s procedure is performed urgently, compared with elective surgery[17]. This supports the assumption that a prophylactic Ladd’s procedure is a reasonable option if asymptomatic intestinal malrotation is diagnosed.

In our case, the indication for surgical intervention was established promptly, given the prior conservative treatment attempt and the relatively rapid recurrence of the same symptoms.

After a review of the literature, it becomes clear that the surgical approach to intestinal malrotation caused by Ladd’s bands in adults is most often performed via laparotomy (72.7%).

27.3% of surgeries started laparoscopically, but in four cases conversion to open surgery was needed due to technical challenges. Catania et al showed that a laparoscopic Ladd’s procedure seems to be better, considering a shorter time to full enteral feeding and a shorter length of hospital stay[22]. Additionally, Takimoto et al showed a laparoscopic approach with fewer conversions in neonates compared with an open procedure[23]. Operating time was significantly longer[23], but adults generally show a much better and faster recovery after laparoscopic surgery[18]. While the laparoscopic approach provides better visualization of the whole abdomen, the mesenteric attachment, and the presence of Ladd’s bands, it is often the better choice[8]. It is assumed to be easier to perform a laparotomy due to too little experience with the laparoscopic Ladd’s procedure in adults[18] and confusing intra-abdominal circumstances. Hence, the recommendation regarding the surgical approach depends on the experience of the team and the operative setting.

Conclusion

In summary, midgut malrotation encompasses a broad clinical spectrum. As this condition is very rare in adults, a high level of diagnostic vigilance, supported by appropriate radiological evaluation, is important for accurate diagnosis. When indicated, surgical management with a Ladd’s procedure effectively relieves symptoms and prevents potentially serious complications. The preferred treatment, in both children and adults, is surgical division of the congenital bands performed via either an open or laparoscopic approach.

Ethical approval

Ethical approval was not required for this case report in accordance with institutional policy. Written informed consent for publication of this case report and the accompanying images was obtained from the patient.

Consent

Written informed consent was obtained from the patient for publication of this case report. The consent form is available from the corresponding author upon reasonable request.

Sources of funding

Supported by the Open Access Publishing Fund of Leipzig University.

Author contributors

J.U., M.M.: Performed surgery, conceived the study, performed th eliterature review and drafted the manuscript. S.M.: Provided intelectual content and revised the manuscript. M.L.: Provided intelectual content and revised the manuscript. H.J.M.: Provided intelectual content and revised the manuscript. S.S.: Provided intelectual content and revised the manuscript. All authors read und approved the final manuscript.

Conflicts of interest disclosure

None of the authors have any conflicts of interest to declare in relation to the present manuscript.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Matthias Mehdorn, MD.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

The data for this case are available from the corresponding author upon reasonable request.

Assistance with the study

None.

Presentation

None.