Journal of Pediatric Surgery 58 (2023) 209–212

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Journal of Pediatric Surgery

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Impact of bowel rotation and fixation on obstructive complications in

congenital diaphragmatic hernia
Kamila Moskowitzova a, Jill M. Zalieckas a, Catherine A. Sheils b, Mollie Studley a,
Lindsay Lemire a, David Zurakowski a, Terry L. Buchmiller a,∗
a
Department of Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA, United States
b
Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, United States

a r t i c l e i n f o a b s t r a c t

Article history: Aim of the study: Small bowel obstruction (SBO) is a known complication after congenital diaphragmatic
Received 5 October 2022 hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel
Accepted 11 October 2022
syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor
for SBO including volvulus.
Keywords: Methods: A retrospective review of 256 CDH survivors following repair from 2003 to 2020 was per-
Malrotation formed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation
Nonfixation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvu-
Small bowel obstruction lus. For statistical analysis Fisher’s exact test was utilized.
Volvulus
Results: Twenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion
were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both
rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation
was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with
extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%).
Conclusions: Malrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is
not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical interven-
tion is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely
documented and education about the risk of SBO should be included in family counseling.
Level of Evidence: Level IV – Case Series
© 2022 Elsevier Inc. All rights reserved.

1. Introduction obstruction in CDH patients is significantly higher than bowel ob-

Congenital diaphragmatic hernia (CDH) is an uncommon, com-
plex disease which most commonly presents in newborns. CDH is
characterized by a diaphragmatic defect through which the abdom-
inal organs herniate into the thoracic cavity, resulting in a complex
mix of pulmonary hypoplasia and pulmonary hypertension. When
associated with congenital heart disease or genetic/syndromic con-
ditions, survival is even further impacted. Survival has markedly
improved over the past several decades with the improvement
in fetal diagnosis and intensive care unit (ICU) management now
reaching overall survival rates of 74–78%, and in isolated CDH with
small defects, even up to 99% [1,2]. Despite these advances in care,
CDH survivors may have considerable morbidity requiring ongoing
multidisciplinary care [3,4].
Surgical complications, specifically bowel obstruction, have
been reported in 8–37% of CDH survivors [5,6,7]. This rate of bowel
∗
Corresponding author at: Boston Children’s Hospital, Department of Surgery,
300 Longwood Avenue- Fegan 3, Boston, MA 02115, United States.
E-mail address: Terry.Buchmiller@childrens.harvard.edu (T.L. Buchmiller).
struction rates in children undergoing laparotomy for other rea-
sons (2.2–8.3%) [8]. Small bowel obstruction (SBO) can be man-
aged non-operatively or may require surgical intervention if con-
servative management fails, or if there is concern for bowel com-
promise. In severe cases, extensive bowel resection may be nec-
essary, which can result in the short bowel syndrome (SBS). This
negatively affects the child’s quality of life with variable periods
of total parenteral nutrition (TPN) dependence and TPN associated
sequela [9]. The etiology of SBO can vary between adhesions, CDH
recurrence, and volvulus, the most feared condition.
CDH is commonly expected to be associated with intestinal
malrotation because of the abnormal prenatal position of the in-
testine because of herniation into the chest cavity in early fetal
life [10,11]. The true incidence of malrotation in CDH patients is
not definitely known, with recent estimates from 42 to 60% [11].
Additionally, not all patients with a CDH have rotational/fixation
abnormalities. In the general population, patients with malrotation
are at risk for obstructive complications and midgut volvulus, with
64–80% presenting in the first month of life and 90% within the
first year [12]. The gold standard for diagnosing malrotation is an

https://doi.org/10.1016/j.jpedsurg.2022.10.019
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210 K. Moskowitzova, J.M. Zalieckas, C.A. Sheils et al. / Journal of Pediatric Surgery 58 (2023) 209–212

upper gastrointestinal series (UGI) showing an abnormal anatomic number, median with range or in percentage, when appropriate.
location of duodenal-jejunal junction (DJJ) [13]. However, CDH pa- Fisher’s exact test was utilized for statistical analysis comparing
tients may have normal rotation, but have abnormal fixation of the complication rates and significance was defined as P<0.05.
bowel because of herniation into the chest, which may predispose
them to obstructive complications. As both bowel rotation and fix- 3. Results
ation in CDH patients are not routinely documented, there is lim-
ited knowledge about the incidence of rotational abnormalities and 3.1. Cohort characteristics
the potential impact on later obstructive complications.
The purpose of this study was to precisely document both the Two hundred fifty-six eligible CDH survivors were identified at
rotation and fixation status of the bowel in CDH survivors at our our institution between 2003 and 2020 (Table 1). The majority
institution, and to investigate if these are predictive of obstructive were males (156, 61%). Median age at repair was 3 days (range 0–
complications, including volvulus. 14.8 years; interquartile range (IQR) 2–5.25 days); 26 had their re-
pair outside of the neonatal period. Median age at follow up was 5
2. Methods years (range 0.1–18 years). CDH was mostly located on the left side
(L CDH, N = 205, 80%). The defect size was type A in 60 (23%), type
2.1. Study cohort B in 76 (30%), type C in 83 (32%) and type D in 12 (5%). Twenty-
five patients (10%) had an undetermined defect. Open repair was
A single center retrospective cohort study was performed in all the most prevalent type of approach in 182 patients (71%). A min-
surviving patients following CDH repair at Boston Children’s Hospi- imally invasive approach, either thoracoscopic or laparoscopic, was
tal between the years 2003 and 2020 via review of electronic med- utilized in 74 patients (29%). Patch repair was performed in 146
ical records. CDH patients are enrolled in the Congenital Diaphrag- patients (57%).
matic Hernia Program at discharge, a multidisciplinary clinic es- The bowel rotation and fixation status were both documented
tablished in 1991, which provides long term multidisciplinary fol- in 117 patients (46%). For 98 patients (38%) only one bowel status
low up care to hundreds of CDH survivors. Our institution has also was evaluable, rotational status in 8 patients, and fixation alone
been continuously participating in the CDH Study Group (CDHSG) in 90 (3% and 35% respectively). No information about bowel sta-
registry since its inception, contributing data outcomes collected tus was discernable in 41 patients (16%). No rotational status was
from the prenatal period through the index hospitalization dis-
charge. Table 1
Patients who did not follow up after discharge, and/or patients Overall cohort characteristics (N = 256).
who had their initial operative repair performed at an outside in-
Variable Data point
stitution were excluded. Only patients with a Bochdalek CDH were
included. Patients with a Morgagni CDH and eventration were not Sex
Male 156 (61%)
included in the analysis.
Female 100 (39%)
The operative notes and UGI studies in our study cohort of Age
CDH patients were reviewed to determine the rotation and fixation Median age at repair 3 (2–5.25; IQR∗ ) d
of the bowel as rotational status is not collected by the CDHSG. Median age at obstruction 1 (0.1–10) y
Records were further screened for the occurrence of SBO as the Median age at follow up 5 (0.1–18) y
Defect side
primary outcome, either treated conservatively or surgically. Fur- L CDH 205 (80%)
thermore, the etiology of bowel obstruction requiring surgical in- R CDH 51 (20%)
tervention was categorized as either secondary to adhesions, CDH Defect type
recurrence, or volvulus (both segmental and midgut). Additionally, Type A 60 (23%)
Type B 76 (30%)
data points including sex, age at repair, defect side, size and type
Type C 83 (32%)
according to the CDHSG classification (type A-D) [14], herniated or- Type D 12 (5%)
gans, type of operative approach, a Ladd procedure at the index Not defined 25 (10%)
operation, age at obstructive complication, and age at the most re- Surgical approach
cent follow up were collected. Open 182 (71%)
Minimally invasive 74 (29%)
Thoracoscopic 68 (26.6%)
2.2. Evaluation of fixation and rotation Laparoscopic 5 (2%)
Combined thoraco- and laparoscopic 1 (0.4%)
We utilized the standard definition of malrotation as an abnor- Repair type
Primary 110 (43%)
mal position of ligament of Treitz upon direct visualization during
Patch 146 (57%)
the initial CDH repair as reported in the operative note or on later Determination of bowel status
UGI. The normal anatomical and radiologic position of the DJJ is to Both rotation and fixation known 117 (46%)
the left of the left vertical body pedicle at the level of the inferior Only 1 bowel status known
margin of the duodenal bulb and located posteriorly on the lateral Only fixation 90 (35%)
Only rotation 8 (3%)
view confirming its retroperitoneal positioning [15]. We defined Unknown bowel status 41 (16%)
nonfixation as lack of lateral colonic attachments observed during Determination of rotation
the initial surgery. CDH survivors were then accordingly categorize Known rotation 125 (49%)
to 6 groups based on bowel status and laterality of diaphragmatic Malrotation 54 (43%)
Normal rotation 71 (57%)
defect as follows: left or right CDH with no malrotation/fixed, no
Unknown rotation 131 (51%)
malrotation/nonfixed, and malrotation/nonfixed. Determination of fixation
Known fixation 207 (81%)
2.3. Statistical analysis Nonfixation 202 (98%)
Normal fixation 5 (2%)
Unknown fixation 49 (19%)
Data were analyzed to determine the impact of bowel rotation
∗
and fixation on obstructive complications and presented as a total IQR (interquartile range).

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 K. Moskowitzova, J.M. Zalieckas, C.A. Sheils et al. / Journal of Pediatric Surgery 58 (2023) 209–212 211

Table 2 later identified on the routine UGI studies. In contrast, 2 patients

Bowel obstruction cohort characteristics (N = 22).
Variable
Bowel status
Fully known
Partially known
SBO requiring surgery
Adhesions
Recurrence
Volvulus w/o resultant SBS
Volvulus w/ resultant SBS
SBO treated conservatively
reported in 131 patients (51%). Of those with known rotational sta-
tus, malrotation was observed in 54 patients (43%) and normal ro-
tation in 71 patients (57%). In patients with documented fixation
status, nonfixation was observed in 202 (98%) and normal fixation
in 5 (2%). No fixation was documented for 49 patients (19%).
3.2. Obstructive complications
Twenty-two patients (9%) presented with SBO (Table 2). Of
these, 17 had the bowel status fully known (77%) and in 5 only
partially known (23%). Most of these patients (19, 86%) underwent
surgical management. SBO was caused by adhesions in 10 (45%),
CDH recurrence in 5 (23%), segmental volvulus not requiring bowel
resection in 1 (4%) and volvulus leading to SBS in 3 patients (2 pa-
tients with segmental volvulus, 9%; 1 patient with midgut volvu-
lus 4.5%). Median age at complication was 1 year (0.1–10 years;
Table 1).
A detailed analysis of obstructive complications (17 patients,
7%) in patients with fully determined bowel status (117 patients,
46%) is presented in Table 3. Presence of left CDH with malrota-
tion and nonfixation was a significant predictor for SBO and SBO
requiring surgery (P < 0.05 vs. all other groups). All 3 patients
with volvulus with SBS had a left CDH with nonfixed bowel (100%),
however only 1 had malrotation (33%). The patient with malro-
tation presented with midgut volvulus, in contrast to the other 2
with segmental volvulus who had normal rotation.
182 patients had their initial repair via laparotomy with 20
(11%) having later obstructive complications. Following initial tho-
racoscopic repair (N = 68), only 2 had obstructive complications
(3%); in both the etiology of SBO was CDH recurrence.
3.3. Patients with volvulus leading to SBS
The occurrence of volvulus is a potentially devastating compli-
cation in CDH patients. Therefore, we present a summary of our
3 patients with either segmental or midgut volvulus who required
extensive bowel resection leading to SBS (Table 4). Of note, the pa-
tient with most severe complication, midgut volvulus, had malro-
tation, which was not evaluated during initial CDH repair, but was
with segmental volvulus, has normal rotation. However, the rota-
Data point tion was also not evaluated during initial CDH repair.
17 (77%)
5 (23%)
4. Discussion
19 (86%)
10 (45%) We report 256 patients in the study cohort, with 125 patients
5 (23%) (49%) having known rotational status. Of those with known rota-
1 (4%)
tional status, 54 patients (43%) had malrotation, and 71 (57%) were
3 (14%)
3 (14%) normally rotated, consistent with prior reports [11]. Surgeons were
more likely to comment of fixation of the colon in the operative
notes. We identified 207 patients (81%) with known fixation sta-
tus. Of those with known fixation, 202 patients (98%) had non-
fixed bowel, and 5 (2%) were normally fixed. To our knowledge
this is the first report describing the fixation of the colon in the
CDH population as a distinct entity from the classic malrotation as
an abnormal DJJ [16].
Bowel obstruction is known surgical complication after CDH re-
pair. We observed a 9% rate of SBO complications in CDH patients,
which is on the lower end of the range previously reported by
others [8]. Patients typically present with obstructive symptoms
within first few years of life, which is in agreement with our obser-
vations [17]. The median age of intestinal obstruction in our cohort
was 1 year, ranging from 0.1 to 10 years of age.
In this study, we investigated both intestinal rotation and fix-
ation as potential determinants of later bowel obstruction in CDH
patients as there is limited knowledge about their impact in the
current literature. ECMO treatment, minimally invasive surgery
(MIS) repair and patch repair are known to be significant predic-
tors for CDH recurrence [18–20]. Accordingly, open repairs, and
those using a patch have been shown to be significant predictors
of SBO [18–20]. In this study, we have shown that malrotation and
nonfixation of the bowel are associated with significantly increased
obstructive complications in the CDH population.
The sided-ness of the CDH defect and the impact of the rota-
tional and fixation status was noteworthy. Previous studies have
reported more severe anomalies with rotation and fixation of the
bowel associated with a right sided hernia likely because of liver
herniation and associated traction on the duodenum via the hep-
atoduodenal ligament [16]. We noted patients with right CDH
were more likely to have malrotation (15 patients, 56%) then left
sided CDH patients (39 patients, 40%). Interestingly, despite having
higher rates of malrotation in right CDH patients, they did not have
higher rates of SBO (6% in right CDH, 9% in left CDH). We hypothe-
size that in right CDH, the liver typically herniates, limiting bowel
herniation into the thoracic cavity. This may invoke less bowel ma-
nipulation during repair potentially leading to a lesser degree of
adhesive disease causing SBO later in life.
The cause of the SBO varied with most common etiology being
adhesions (45%). No patients with a MIS repair had an adhesive
bowel obstruction, but 2 who underwent thoracoscopic repair, had

Table 3
Obstructive complications in patients with fully determined bowel status (N = 117).

Bowel Rotation and Fixation Small Bowel Small Bowel Obstruction Requiring Surgical Intervention
Obstruction
Overall Adhesions Recurrence Volvulus w/o SBS Volvulus w/ SBS

Left CDH no malrotation / fixed 0/1 (0%) 0/1 (0%) 0/1 (0%) 0/1 (0%) 0/1 (0%) 0/1 (0%)
Left CDH no malrotation / 5/53 (9.4%) 4/53 (7.6%) 2/53 (4%) 0/53 (0%) 0/53 (0%) 2/53 (4%)
nonfixed
Left CDH malrotation / nonfixed 10/39 (25.6%)∗ 9/39 (23.1%)∗∗ 6/39 (15.4%) 1/39 (2.6%) 1/39 (2.6%) 1/39 (2.6%)
Right CDH no malrotation / fixed 1/2 (50%) 1/2 (50%) 1/2 (50%) 0/2 (0%) 0/2 (0%) 0/2 (0%)
Right CDH no malrotation / 0/7 (0%) 0/7 (0%) 0/7 (0%) 0/7 (0%) 0/7 (0%) 0/7 (0%)
nonfixed
Right CDH malrotation / nonfixed 1/15 (6.7%) 0/15 (0%) 0/15 (0%) 0/15 (0%) 0/15 (0%) 0/15 (0%)
∗
P = 0.025 vs. all other groups.
∗∗
P = 0.014 vs. all other groups.

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212 K. Moskowitzova, J.M. Zalieckas, C.A. Sheils et al. / Journal of Pediatric Surgery 58 (2023) 209–212
Table 4
Summary of 3 patients with volvulus leading to short bowel syndrome.
Case CDH Side Type of Repair Age at Fixation
Repair
1 Left open, primary DOL 2 nonfixation
identified in OR
2 Left open, patch DOL 0 nonfixation
identified in OR
3 Left open, patch DOL 5 nonfixation
identified in OR
an SBO because of CDH recurrence. The most concerning cause of
SBO is volvulus, both segmental or midgut, which should be high
on the differential when evaluating CDH patients with obstructive
presentation. Others have hypothesized that adhesions following
CDH repair can actually be protective from volvulus [16]. However,
in our cohort, adhesions contributed to the volvulized bowel in all
3 patients.
SBO requiring surgical intervention is extremely common in
CDH patients as 86% who presented with SBO underwent surgery.
Most patients with SBO underwent open CDH repair initially (91%).
In the malrotation cohort we identified 54 patients; in 17 pa-
tients (32%) malrotation was identified during initial CDH repair.
This is much lower rate than 70% of intraoperative diagnosis of
malrotation in CDH population reported by others [21]. Ten un-
derwent a prophylactic Ladd procedure after malrotation was ob-
served. In the malrotated patients who underwent a Ladd proce-
dure, only 1 developed an SBO and no volvulus was observed (10%
in this subset vs. 19% in the overall cohort). The performance of a
Ladd procedure is not standard, particularly if the operation is be-
ing performed on ECMO, and therefore its utility was not evaluable
in this study. There is no clear guideline regarding management of
asymptomatic malrotation in the CDH population with recent stud-
ies concluding that there is a lack of quality data to guide the man-
agement [22]. Based on our observations, rotational status should
be evaluated during the initial surgery and with a Ladd procedure
considered. Further study as to the applicability of a Ladd proce-
dure during the index operation is warranted as a recent study
showed CDH patients with malrotation diagnosed during follow-
up have a higher likelihood of an SBO [11].
A limitation of this study is the retrospective nature of the re-
view. In some cases, we were not able to use partial or unclear
data in the operative reports to categorize the bowel status of the
patients.
In conclusion, we have shown that malrotation and nonfixation
are associated with increased obstructive complications in CDH.
Normal rotation is not protective and patients are still at risk for
significant segmental volvulus. Furthermore, malrotated patients
without a Ladd procedure may be at higher risk for SBO includ-
ing volvulus. Overall, we conclude that the bowel rotation and fix-
ation status are individual important determinants of later obstruc-
tive complications that should be routinely evaluated, and recorded
during the index operation if possible. The protective effect of a
potential Ladd procedure in the later occurrence of bowel obstruc-
tion warrants further study and must be balanced with an ex-
tended operation in this critically ill population at birth. Ongoing
active education about the risk of SBO should be included in family
counseling after the index operation both prior to discharge home,
and in the long-term follow-up clinics.
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Rotation Age at Volvulus Short Bowel
Presentation Syndrome
Malrotation identified 6 years old midgut volvulus 41 cm of residual
on routine UGI for identified on CT small bowel
GERD
no malrotation 7 weeks old segmental volvulus 95 cm of residual
identified in OR for identified on UGI small bowel
volvulus
no malrotation 4 years old segmental volvulus 130 cm of residual
identified on UGI identified in OR small bowel
during hospitalization
for volvulus
References
[1] Harting MT, Lally KP. The congenital diaphragmatic hernia study group registry
update. Semin Fetal Neonatal Med 2014;19(6):370–5.
[2] Kays DW, Islam S, Larson SD, et al. Long-term maturation of congenital di-
aphragmatic hernia treatment results toward development of a severity-spe-
cific treatment algorithm. Ann Surg 2013;258:638–46.
[3] Putnam LR, Harting MT, Tsao K, et al. Congenital diaphragmatic hernia defect
size and infant morbidity at discharge. Pediatrics 2016;138(5):e20162043.
[4] Safavia A, Synnesb AR, O’Brienc K, et al. Multi-institutional follow-up of pa-
tients with congenital diaphragmatic hernia reveals severe disability and vari-
ations in practice. J Pediatr Surg 2012;47:836–41.
[5] Betremieux P, Lionnais S, Beuchee A, et al. Perinatal management and outcome
of prenatally diagnosed congenital diaphragmatic hernia: a 1995–20 0 0 series
in Rennes University Hospital. Prenat Diagn 2002;22:988–94.
[6] Jancelewicz T, Chiang M, Oliveira C, et al. Late surgical outcomes among con-
genital diaphragmatic hernia (CDH) patients: why long-term follow-up with
surgeons is recommended. J Pediatr Surg 2013;48:935–41.
[7] Colvin J, Bower C, Dickinson JE, et al. Outcomes of congenital diaphragmatic
hernia: a population-based study in Western Australia. Pediatrics (Evanston)
2005;116(3):356–63.
[8] Bagolan P, Morini F. Long-term follow up of infants with congenital diaphrag-
matic hernia. Semin Pediatr Surg 2007;16:134–44.
[9] Khalil B, Ba’ath ME, Aziz A, et al. Intestinal rehabilitation and bowel recon-
structive surgery: improved outcomes in children with short bowel syndrome.
J Pediatr Gastroenterol Nutr 2012;54:505–9.
[10] Baoquan Q, Diez-Pedro JA, Tovar JA. Intestinal rotation in experimental con-
genital diaphragmatic hernia. J Pediatr Surg 1995;30(10):1457–62.
[11] Heiwegen K, de Blaauw I, van Ling J, et al. Malrotation in congenital diaphrag-
matic hernia: is it really a problem? Eur J Pediatr Surg 2020;30:434–9.
[12] Butterworth WA, Butterworth JW. An adult presentation of midgut volvulus
secondary to intestinal malrotation: a case report and literature review. Int J
Surg Case Rep 2018;50:46–9.
[13] Sizemor AW, Rabbani KZ, Ladd A, et al. Diagnostic performance of the upper
gastrointestinal series in the evaluation of children with clinically suspected
malrotation. Pediatr Radiol 2008;38:518–28.
[14] Lally JP, Lasky RE, Lally PA, et al. Standardized reporting for congen-
ital diaphragmatic hernia – an international consensus. J Pediat Surg
2013;48:2408–15.
[15] Applegate KE. Evidence-based diagnosis of malrotation and volvulus. Pediatr
Radiol 2009;39(S2):161–3.
[16] Levin TL, Liebling MS, Ruzal-Shapiro C, et al. Midgut malfixation in patients
with congenital diaphragmatic hernia: what is the risk of midgut volvulus?
Pediatr Radiol 1995;25:259–61.
[17] Jancelewicz T, Paton EA, Jones J, et al. Risk-stratification enables accurate sin-
gle-center outcomes assessment in congenital diaphragmatic hernia (CDH). J
Pediatr Surg 2019;54:932–6.
[18] Janssen S, Heiwegen K, van Rooij IALM, et al. Factors related to long-term sur-
gical morbidity in congenital diaphragmatic hernia survivors. J Pediatr Surg
2018;53:508–12.
[19] St Peter S, Valusek PA, Tsa K, et al. Abdominal complications related to type of
repair for congenital diaphragmatic hernia. J Surg Res 2007;140:234–6.
[20] Putnam LR, Tsao K, Lally JP, et al. Minimally invasive vs open congenital
diaphragmatic hernia repair: is there a superior approach? J Am Coll Surg
2017;224(4):416–22.
[21] Zani A, Eaton S, Puri P, et al. International survey on the management of con-
genital diaphragmatic hernia. Eur J Pediatr Surg 2016;26:38–46.
[22] Graziano K, Islam S, Dasgupta R, et al. Asymptomatic malrotation: diagno-
sis and surgical management an American pediatric surgical association out-
comes and evidence based practice committee systematic review. J Pediatr
Surg 2015;0:1783–90.