Rotational anomalies of the midgut... what's what?

At least once a year, a funny looking UGI study sparks the traditional discussion on rotational anomalies of the GI tract. And the fact that radiologists and surgeons don't necessarily agree on the terms used to describe different types of rotational anomalies doesn't help. Assuming radiologic findings reflect intra-operative findings (and this is assuming with a capital "A"), the following classification is helpful.

Rotational anomalies refers to situations where normal 270 degree counter-clockwise rotation and subsequent fixation of the bowel between the 5th to 10th week of gestation is not completed. Normal rotation results in a wide mesenteric base, which protects the bowel from volvulus (Fig 1. Red line). The most important implication of rotational anomalies is that they result in a spectrum of abnormal mesenteric base lengths, and subsequently variable risks for midgut volvulus. Based on the radiologic literature, the two main types of intestinal rotational anomalies are incomplete rotation and non-rotation.

In the case of incomplete rotation, the most common type, the proximal and distal midgut both rotate between 90 and 180 degrees. This places both the duodeno-jejunal junction (DJJ) and the cecum in close proximity to each other, and thus results in a narrow mesenteric base, prone to volvulus (Fig 2).

The second most common type of rotational anomaly is intestinal non-rotation. In this form, there is minimal rotation (<90 degrees) of both the proximal and distal midgut. This keeps the proximal mesenteric attachment (DJJ) and the distal attachment (cecum) far enough from each other that the risk of volvulus is much lower than that with incomplete rotation.

Although this is a useful classification, it is important to always keep in mind that radiologic findings do not necessarily always reflect true anatomy, and the potential for false positive and negative findings on UGI exist.

Shew S B. Surgical concerns in malrotation and midgut volvulus. Pediatric Radiology (2009); 39:S167-181

My take-home summary of PS233 : To tweet or become extinct?: why surgeons need to understand social networking

The panel discussion started at 230 pm with an enthusiastic crowd and a very welcomed skepticism from a few of the attendants. I say welcomed because such skepticism is critical in keeping a check on how we use social media. Patients are NOT our friends (thank you @jcparamo), but they can be fans of your practice’s FB page, which can be configured to work like a read-only “yellow page” (via @Z1G1).

Dr Philip Glick kicked off the discussion by encouraging the audience to sign up on Twitter and engage the panel through a live Twitter feed (which I’m very pleased to say, many did). Someone even coined the term “loss of Twitter virginity” at the session!
Dr Glick then showed some statistics that reflect the use of social media by members of the American College of Surgeons (ACS). Only one third of ACS members participate in online forums or read online health blogs, which are a major player in patient education. If patients go to health blogs and forums for information, and we are not participating in them, WHO is giving them information?

Zach Glick then proceeded to give the audience an introduction to Twitter, including how to set up the account and “tweak” security setting. Always remember to look for boxes checked by default and uncheck them as necessary! Zach’s section helped audience members sign up on Twitter there and then and experience it’s capacity to spread and exchange information instantaneously by transmitting their tweeted comments and criticisms to a live Twitter feed projected on a screen in the room.

In my section I discussed the use of Twitter in the spread and exchange of information. Twitter’s reputation as a social gimmick has given it a “bad rap”, to the extent that it is difficult to get other surgeons to even listen to the argument for its use. Fortunately, Twitter has become more of a tool used to spread and exchange information than a way to keep up with your friends’ minute to minute activity. When a group of surgeons of similar interest are linked through Twitter, they can exchange pertinent information they find on the web (whether it’s a great YouTube video, or a blog that can help with patient education, or an excellent paper) by sending out a brief tweet with a link (shortened URL) to that source.

Twitter can help surgeons sift through the mass of information on the internet, share what’s relevant, and enrich it with their own thoughts and experiences.

Sussanah Fox (our social media guru!), discussed the different levels of participation in social media, from “lurking” and simply listening-in on what others have to say, to sharing interesting findings with others, to actually creating and contributing to online content. I found this section particularly interesting, given that several of the surgeons in the audience voiced their concern about tweeting and blogging “on a daily basis”. We do not all have to contribute to these resources, but they are there for us to use and experience. We do not have to jump into the deep end right away (via @SusannahFox). I think surgeons should start with simply searching for blogs and forums that discuss medical education (blogs.usask.ca/medical_education), surgical issues (forsurgeons.net), and provide patients with information (preop.com) to get an idea of what’s “out there”. Some may proceed to share and create, others may just keep listening. But I truly believe that we have to, at least, listen.

Rebekah Monson, as Susannah put it, made us all feel appropriately apprehensive about social media. Her contribution was central to bringing home the point that social media, when integrated into our professional, and personal lives for that matter, must be handled with care and reason. She also brought the point home by pointing out that employers hire and fire based on the contents of social media.

Dr Scott Lind wrapped up the session by giving examples of how social media can be incorporated into a practice, sighting how the Georgia Society of the American College of Surgeons has created a mobile app! He also discussed the issue of how surgeons are perceived as arrogant and aloof, based on a patient survey, and how the use of social media can help fight that perception.

The session ended with some very relevant question by the audience, including some very legitimate concerned voiced.

Overall I learned a lot from this panel discussion and particularly from the audience’s reaction and participation. Surgeons seem to be very interested in social media, but have legitimate concerns about ramifications.

ACS congress news report at:
http://www.facs.org/clincon2010/press/thurs.pdf

Bulletin of American College of Surgeons article:
http://www.facs.org/fellows_info/bulletin/2011/peregrin0211.pdf