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Malrotation of the gut can present at any age but the majority of patients present in neonatal period or early infancy. Most children present with a history of recurrent colicky abdominal pain, vomiting which can be bilious and failure to thrive. Delay in diagnosis leads to increase in mortality and morbidity. Here we present a series of three patients, one girl aged 6 years, one 10 months old boy and one 10 years old boy, who got admitted at our Pediatric Department in a one month period. Patients had a history of recurrent abdominal pain and occasional vomiting, seen and managed by multiple paediatricians and GP doctors with extensive diagnostic workup but never the accurate diagnosis was made. Thorough history was taken and examination done, planned work up done for diagnosis. High index of suspicion is needed in children presenting with recurrent pain in the abdomen. Targeted work-up should be done and patients be kept on follow-up for diagnosis of late presentation of congenital malrotation of the gut.

Malrotation of the gut can present at any age but the majority of patients present in neonatal period or early infancy. Most children present with a history of recurrent colicky abdominal pain, vomiting which can be bilious and failure to thrive. Delay in diagnosis leads to increase in mortality and morbidity. Here we present a series of three patients, one girl aged 6 years, one 10 months old boy and one 10 years old boy, who got admitted at our Pediatric Department in a one month period. Patients had a history of recurrent abdominal pain and occasional vomiting, seen and managed by multiple paediatricians and GP doctors with extensive diagnostic workup but never the accurate diagnosis was made. Thorough history was taken and examination done, planned work up done for diagnosis. High index of suspicion is needed in children presenting with recurrent pain in the abdomen. Targeted work-up should be done and patients be kept on follow-up for diagnosis of late presentation of congenital malrotation of the gut.

Background: Intestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer. Case presentation: A 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma. Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I. Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes. Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation. Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was

The pattern of anatomical organization of the thoraco-abdominal visceral and vascular structures which is not the expected normal arrangement, is called as situs ambiguous or heterotaxy syndrome. Patients with heterotaxy syndrome exhibit a wide spectrum of anatomical variations involving thoraco-abdominal structures. We present here an incidental finding of heterotaxy syndrome associated with unique vascular anomalies in a 35 year old male patient evaluated initially for nephrolithiasis by ultrasonography, and intravenous pyelography. Further evaluation by multidetector row computed tomography showed bilateral bilobed lungs with hyparterial bronchi, cardiac apex to the left, five branches from left-sided aortic arch with retroesophageal right subclavian artery, interrupted inferior vena cava with azygos continuation, left renal vein continuing as hemiazygos vein and replaced common hepatic artery arising from the superior mesenteric artery. Other vascular anomalies include right internal iliac vein joining the left common iliac vein and precaval course of the single main right renal artery. Anomalies involving abdominal organs include right-sided stomach, midline liver, multiple splenules (polysplenia) in right upper quadrant of abdomen, short truncated pancreas, intestinal malrotation, inversion of superior mesenteric vessels and a preduodenal portal vein. To the best of our knowledge this is the first report of association of left renal vein continuing as hemiazygos vein, precaval right renal artery and anomalous branching pattern of aortic arch with heterotaxy syndrome.

Infants with malrotation of the gut easily develop midgut volvuluse If this volvulus is not treated immediately, ischemic necrosis of the small bowel may develop rapidly. The treatment of these children requires extensive small bowel resection. Infrequently, children are born with multiple jejunal or ileal atresias or with an 'apple peel' type of small bowel atresia. Both after massive small bowl resections and in severe atresias, the child is left with a very short length of bowel and great difficulties to thrive. Fortunately, with time both functional an::l morphological adaptation of the remnant small bowel occurs. In the neonatal period it is not clear whether growth of the small bowel after a massive resection is part of normal growth or ~hether it is due to, or may be enhanced by, adaptational responses. Neonates, especially in the recovery stage from intestinal surgery, often have to be fed parenterally, or later, with artificial milk formulas. It is known from experiments in adult animals, that oral feeding stimulates adaptation of small intestine after resections. In the newborn, colostrum seems to provide a special stimulus for gut growth, as has been suggested by animal studies and by experiments in vitro. Therefore, we thought it could be important to examine the effects of colostrum, of breast milk produced later in lactation, and of a commercial milk formula on normal development and on adaptation to resection of the intestine. l'le also studied the effect of the presence of food in the small bowel on development and adaptation. Some of the components of breast milk which are not present in artificial formulas are macromolecules, especially y-globulins, and viable rnacrophages. Breast milk provides passive immunity in some species and other host resistance factors, protecting the suckling in most species. Furthermore it has a regulatory effect on bacterial colonization in the bowel. Since necrotizing enterocolitis occurs with much lower frequency in br