Malrotation: some answers but more questions

Excerpt

The historical review by Lampl et al. [1] helps us to understand our continual conundrum about the diagnosis and misdiagnosis of malrotation. When a child has obvious malrotation (Table 1), the diagnosis is easy. However, when there are minor deviations of the position of the duodenal-jejunal junction on the upper gastrointestinal examination, the correct diagnosis becomes more difficult and is the cause of confusion. Why, in those with no abnormality found at surgery or with an unremarkable follow-up, may the duodenal-jejunal junction be lower than it should be and not reach the level of the duodenal bulb? Why, in those with no abnormality found, may the duodenal-jejunal junction be more midline and not cross the spine entirely? If the “ligament of Treitz” is truly a ligament (fibrous, nonstretchable structure), this should not occur. However, Lampl et al. [1] point out that this ligament is not only a ligament but also a muscle—the original description by Václav Treitz. When one goes to Gray’s Anatomy [2], we find “The ligament of Treitz may contain a small slip of muscle, the suspensory muscle of the duodenum. When present, the suspensory muscle contains skeletal muscle fibres that run from the left crus of the diaphragm to connective tissue around the coeliac axis, and smooth muscle fibres that run from the coeliac access: its function is unknown.” Obviously, muscle can stretch. When there is dilatation of the stomach, colon, or small bowel, the duodenal-jejunal junction may be pushed downward and/or toward the midline. The “stretchability” of the ligament of Treitz helps to explain the seeming malposition of the duodenal-jejunal junction in some normal patients. …